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Form Cacl 280.200 Application For Requesting Approval To Surrender Capital Access Company Law License - California Commissioner Of Corporations

File No. ____________________________

Date of Application ___________________

COMMISSIONER OF CORPORATIONS

STATE OF CALIFORNIA

APPLICATION FOR REQUESTING APPROVAL TO SURRENDER

CAPITAL ACCESS COMPANY LAW LICENSE

PURSUANT TO SECTION 28650 OF THE CORPORATIONS CODE

The Application for Requesting Approval to Surrender a Capital Access Company Law License

MUST BE TYPEWRITTEN and may only be filed in the Sacramento Office of the Department

of Corporations.

Name of Applicant: ________________________________________________________

Name under which business is conducted, if different from above:

________________________________________________________________________

Address of actual location of principal place of business:

________________________________________________________________________

No. and Street

City

State

ZIP Code

State the reason for surrendering the license: ___________________________________

________________________________________________________________________

Does the applicant owe any money or securities to any investor?

( ) Yes ( ) No

If answer is “yes”, furnish all of the following information:

Amount of money owed:

$_________________________________________

Arrangements made for the payment of the money owed:

________________________________________________________________________

Market value of securities (if applicable): ________________________________

Arrangements made for the return or delivery of securities: __________________

________________________________________________________________________

Has applicant assigned any of its contracts to another person?

( ) Yes ( ) No

If answer is “yes” furnish all of the following information:

Name and business address of the person(s) to whom the contracts were assigned:

_______________________________________________________________________

Name of contact person: _____________________________________________

What alternative was provided with respect to those investors who did not consent

to the assignment of their contracts? ____________________________________

________________________________________________________________________

CACL 280.200

Form Cacl 280.200 Application For Requesting Approval To Surrender Capital Access Company Law License - California Commissioner Of Corporations