Form Fis 0557 - Ace-Net Report Form printable pdf download

Form Fis 0557 - Ace-Net Report Form

This form is issued under Act 265, PA 1964, as amended.

FIS 0557 (5/04)

Office of Financial and Insurance Services

This form must be completed pursuant to the ACE-NET

exemption under Section 402(b)(20) of the Act. Failure

to file will disqualify the issuer from utilizing this exemption.

MICHIGAN DEPARTMENT OF LABOR & ECONOMIC GROWTH

OFFICE OF FINANCIAL AND INSURANCE SERVICES

ACE-NET REPORT FORM

INSTRUCTIONS: This form must be filed to comply with the ACE-NET exemption from registration pursuant to Section 402(b)(20) of

the Michigan Uniform Securities Act. The Report must be filed within 15 days of the first Michigan sale by the Issuer and must be

signed by an authorized agent or representative.

Issuer

Address

Description of Securities

Date that offering was initiated in Michigan

Signature of Authorized Agent or Representative

Title

Date Signed

RETURN TO:

Michigan Department of Labor & Economic Growth

Office of Financial and Insurance Services

Securities Section

P.O. Box 30701

Lansing, MI 48909

Form Fis 0557 - Ace-Net Report Form