Form 203-P - Notice Under Section 203(P) Of The Pennsylvania Securities Act Of 1972 Page 4
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54.
(A)
Legal Form of Issuer (corporation, partnership, association, etc.):_____________
(B)
State and Date of Incorporation:
_____________________________________________________________________
State
Date
(C)
Name of any Predecessor of Issuer:_______________________________________
(D)
Purpose for which Issuer was formed and nature of its activities:
_______________________________________________________________________
5.
(A)
Describe type and amount of securities proposed to be sold, price per unit, and
anticipated total net proceeds to the Issuer. List separately the amounts proposed
to be paid for the costs of the offering and any underwriting fee or sales
commissions. Identify all persons who will receive any such fee or commission
and the basis on which it will be paid. Identify also any person who will receive
any monies for assistance rendered in developing the offering plan and the
amount of compensation paid, or to be paid, to each such person.
(B)
Describe any subordination, sinking fund, call and all other material provisions
of the securities being offered and any assets in which a mortgage or security
interest is being created for the benefit of the securityholders.
(C)
Attach a copy of the security being sold.
(D)
Attach a copy of an appraisal or other document indicating the fair market value
of the collateral.
(E)
Describe the terms of any escrow being created to satisfy the requirements of
Section 203(p)(5).
6.
Describe in detail the intended use of proceeds from the offering, stating the amounts to
be used for each purpose and order of priority of uses indicated.
7.
State the Section of the Internal Revenue Code under which Issuer claims tax exempt
status, if any. ____________________________________________
Has any such tax exemption ever been challenged?
YES
NO
If yes, describe fully all surrounding facts and circumstances and state the result of such
challenge.
8.
Has the Issuer, within the previous two years, sold securities in Pennsylvania?
YES
NO
If YES, describe the circumstances under which sales were made, including: (i) offering
prices; (ii) the dates, classes and amounts of securities sold; (iii) the exemption or other
provision of the Act or regulations of the Commission relied upon in each instance.
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