APPLICATION FOR CERTIFICATION AS A
CERTIFIED CAPITAL COMPANY
SUSAN COMBS • TEXAS COMPTROLLER OF PUBLIC ACCOUNTS
Attach a separate page if space provided in this form is insufficient to fully answer any question. Any additional page or
supporting document that is attached to and/or enclosed with this application shall be clearly labeled with the Section and
Item number to which it pertains.
ATTACHMENTS
1. Detailed Plan of Operation for the CAPCO, including:
(a) Mission statement;
(b) Description of Business/Business Plan;
(c) Organizational structure; and
(d) Service providers and responsibilities.
2. Certified copy of CAPCO Certificate of Incorporation, Articles of Incorporation, Charter and By-Laws, Certificate
of Formation of a limited partnership, trust documents, or other organizational documents that evidence that
the prospective CAPCO is duly organized and qualified to do business in Texas, and an opinion of counsel
that the prospective CAPCO is duly organized and qualified to do business in Texas.
3. A copy of any prospectus or offering material used in the sale of securities of the CAPCO.
4. Description of sources of funds for shareholders indicated in Item A.5, if applicable.
5. A copy of the executed management agreement indicated in Item A.7, if applicable.
6. Biographical affidavits for all individuals identified in Items A.7, A.8, A.9, and A.10.
7. Description of venture capital experience of principals and/or manager.
8. Affidavits (Form 25-116) for all individuals identified in Items A.7, A.8, A.9, and A.10.
9. Certified copy of the Resolution (Form 25-111).
Please complete all fields using “NO,” “NONE,” or “NOT APPLICABLE,” if appropriate.
Check type of application:
ORIGINAL
RESUBMISSION
AMENDMENT
A. GENERAL
1. Name of Proposed Certified Capital Company (“CAPCO”)
Contact person
Daytime phone (Area code and number)
2a. Mailing address of CAPCO
Street
City
State
ZIP code
AP-213-1 (Rev.1-07/2)