Notification Of Claim Of Exemption Form - State Of Washington printable pdf download

Notification Of Claim Of Exemption Form - State Of Washington

Notification of Claim of Exemption

Department of Financial Institutions

Securities Division

Nonprofit Organization - RCW 21.20.310(11)

P.O. Box 9033

Olympia, WA 98507-9033

360-902-8760

(If insufficient space is available for answers, please attach sheet with additional information)

Issuer

Name

Address

(

)

Phone Number

Officers and directors

Names, Addresses and Phone numbers

Nature and purposes of organization

As basis for claiming exemption

Issuer is a

1 religious

2 educational

3 charitable

4 fraternal

organization

(check one)

Include proof of current tax exempt status under the Internal Revenue Code.

This offering

Description of security

Price per security

Number of securities to be offered

Short description of the proposed use of proceeds from the sale of securities

Issuer shall provide a prospective purchaser written information regarding the securities offered prior to

consummation of any sale, which information shall conspicuously disclose the following statements:

SC-610-231 (R/5/94)W Page 1 of 2

Notification Of Claim Of Exemption Form - State Of Washington