Quarterly Report Form - Washington For Validation Only Department Of Financial Institutions

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STATE OF WASHINGTON
FOR VALIDATION ONLY
Department of Financial Institutions
Securities Division
PO Box 9033
Olympia, WA 98507-9033
360-902-8760
QUARTERLY REPORT FORM
NUMBER ______________________
REGISTRATION IN THE NAME OF
______________________________________________________________
______________________________________________________________
AUTHORIZING THE SALE AND DISTRIBUTION OF ___________________________________________________
___________________________________________________
1. THE FOLLOWING REPORT IS FOR THE QUARTER ENDING __________________________, 19 ______ .
2. SECURITIES SOLD:
NO. OF SHARES/UNITS
DOLLAR AMOUNT
THIS QUARTER
______________________________
______________________________
PRIOR QUARTERS
______________________________
______________________________
TOTAL TO DATE
______________________________
______________________________
ON A SEPARATE SHEET LIST ALL INVESTORS SOLD THIS QUARTERS SHOWING THE AMOUNT
BOUGHT BY EACH INVESTOR AND DATE OF PURCHASE (EXHIBIT “ A” ).
3. SELLING COST:
AMOUNT
PERCENT OF SALES
THIS QUARTER
______________________________
______________________________
PRIOR QUARTERS
______________________________
______________________________
4. IMPOUND (IF APPLICABLE)
IMPOUND AGENT (Bank-Savings & Loan, etc.) _________________________________________________
ADDRESS _______________________________________________________________________________
TOTAL AMOUNT OF IMPOUND TO BE REACHED ______________________________________________
DATE IMPOUND EXPIRES _________________________________________________________________
AMOUNT IMPOUNDED THIS QUARTER
. . . . . . . . . . . . . . . . . . . . .
$ ________________________
AMOUNT IMPOUNDED PRIOR QUARTER
. . . . . . . . . . . . . . . . . . . . .
$ ________________________
TOTAL IN IMPOUND ACCOUNT TO DATE
. . . . . . . . . . . . . . . . . . . . .
$ ________________________
SC-610-044 QUARTERLY REPORT (R/10/91) Page 1 of 2

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