Notice Of Issuance Of Shares Form - California Commissioner Of Corporations
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4(Department of Corporations
DEPARTMENT OF CORPORATIONS
Use Only)
FILE No., if any:
Fee Paid $ ___________________
______________________________
(Insert File Numbers(s) of Previous
Receipt No. __________________
Filings Before the Department, If Any)
FEE: $25.00 $35.00 $50.00 $150.00 $300.00
(Circle the appropriate amount of fee.
See Corporations Code Section 25608(c))
TO THE COMMISSIONER OF CORPORATIONS OF THE STATE OF CALIFORNIA
Notice of Issuance of Shares Pursuant to Subdivision (h) of
Section 25102 of the Corporations Code or Rule 260.103,
Title 10, California Code of Regulations.
Check one of the following:
( )
Notice pursuant to Section 25102(h) as to an issuance subject to qualification under
Corporations Code Section 25110, unless exempted.
( )
Notice pursuant to Rule 260.103 as to an issuance subject to qualification under
Corporations Code Section 25120, unless exempted.
Name of Issuer
_______________________________________________________________________________
State of Incorporation
_______________________________________________________________________________
Address of Principal Place of Business
_______________________________________________________________________________
Number and Street
City
State
Zip Code
1.
Is the issuer a "close corporation" as defined in Section 260.001, Title 10, California Code of
Regulations?
( ) Yes
( ) No
Instruction: Review Corporations Code Section 158 and Rule 260.001, Title 10, California
Code of Regulations.
2.
Under the exemption provided by Section 25102(h), shares of voting common stock have
been or are proposed to be issued pursuant to this Notice beneficially to not more than 35
persons, whose names are set forth below; together with the names of the corresponding
record shareholders if other than the beneficial shareholders:
_______________________________
__________________________________
_______________________________
__________________________________
_______________________________
__________________________________
_______________________________
__________________________________
_______________________________
__________________________________
If additional space is needed for the names of shareholders, check this box and attach a
separate sheet of paper to the Notice.
[ ]
260.102.8 (a) (Revised 5/97)
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