Quartely Report Form For Small Mining Issues Form

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IDAHO DEPARTMENT OF FINANCE
Securities Bureau
PO Box 83720
Boise, ID 83720-0031
QUARTERLY REPORT FORM FOR SMALL MINING ISSUES
1. Name of Issuer: _______________________________________
Qtr.Ending: ______________________
Address: _____________________________________________
Permit No.: ______________________
2. Number of shares sold this report: _______________ To date under Permit: _____________________
3. Number of purchasers this report: _______________ To date under Permit: _____________________
4. Amount of money obtained from sales this report: ______________________ To date:_________________
5. Purpose for which monies were used including:
This Report
Year to Date
a.
Salaries & Wages
$ __________
$ ______________
b.
Repairs
$ __________
$ ______________
c.
Rent
$ __________
$ ______________
d.
Taxes
$ __________
$ ______________
e.
Interest
$ __________
$ ______________
f.
Advertising
$ __________
$ ______________
g.
Promotional Expense
$ __________
$ ______________
h.
Commissions to selling persons
$ __________
$ ______________
Exploration, Development and Mining
i.
Operation:
1. Payroll
$ ______________
2. Supplies
$ ______________
3. Equipment
$ ______________
4. Legal fees
$ ______________
5. Accounting
$ ______________
6. Engineering
$ ______________
7. Geological
$ ______________
8. Royalties
$ ______________
9. Lease Expense
$ ______________
TOTAL:
$ ___________
$ _____________
============
=============
Total monies used
$ ___________
$ _____________
(Issuer) ____________________________
(Title) ____________________________

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