Sec Form Fp - Statement Of Revenue printable pdf download

Sec Form Fp - Statement Of Revenue

Page 292 of 346

Exhibit 3d. Form FP-Statement of Revenue

Form FP-Statement of Revenue

Pursuant to Funding Portal Rule 300(e), each funding portal member must report its gross revenue on this

form no later than 60 calendar days following the end of the calendar year.

GENERAL INFORMATION

Full Name of Funding Portal Member: ________________________

SEC File Number: ________________________

Organization ID: ________________________

IRS Tax Number: ________________________

Business Address: ________________________

Website Address(es) at which Business is Conducted: ________________________

IN THE SPACE BELOW, INDICATE GROSS REVENUE EARNED IN THE CALENDAR YEAR INDICATED

For the period 01/01/2XXX to 12/31/2XXX

Total: $_____________

Designated Signatory

I hereby certify under penalty of perjury under the laws of the United States of America, 28 U.S.C. §

1746, that the foregoing information provided by me on behalf of [name of funding portal] is true and

correct to the best of my knowledge, information, and belief and that I am legally authorized to make

the foregoing certification on behalf of [name of funding portal].

Executed on: ____________________, 20______.

Executive Officer Signature:

______________________________________

Print Name:

______________________________________

Sec Form Fp - Statement Of Revenue