Form 14-2n - Uniform Limited Offering Exemption Final Report - 1998
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1(Rev. 11/16/98)
STATE OF UTAH
DEPARTMENT OF COMMERCE
DIVISION OF SECURITIES
FORM 14-2n
Uniform Limited Offering Exemption Final Report
Date
1.
Name of Issuer:
2.
Address of Issuer:
City:
State:
Zip Code:
3.
Title of Securities Being Sold:
4.
Amount sold in all states:
# Units/Shares
Cash Received
Amount Receivable
5.
Amount sold in Utah:
# Units/Shares
Cash Received
Amount Receivable
6.
Number of Units in total offering:
7.
Issue being sold in Utah by:
8.
Commissions are being paid to the following Utah salespersons (include full names, social security and/or
Central Registration Depository (CRD) numbers):
at
%.
9.
Attach a list of persons who have purchased or subscribed to the offering in Utah, including their residential
address, the dates of purchase, amount purchased, and state whether they purchased as an accredited or non-
accredited investor.
Signature
Name of Issuer
Title
Subscribed and sworn to before me this
day of
,
.
Notary Public
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