Form Fis 0559 - Securities Report
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1FIS 0559 (5/04) Office of Financial and Insurance Services
This form is issued under Act 265, PA
1964, as amended. You must file this
form as required by Order of the
Administrator pursuant to Section
305(i) and Rule 705.4
SECURITIES REPORT
Issuer
File No.
Description of Securities
Report Date (Report date is the expiration of the Registration Order unless offering is terminated prior to the expiration of the Registration Order; in which
case, the report date is the date of termination.)
Report of Sales:
Registered in Michigan
Total Sold in Michigan
$
$
This report is accompanied by
Date offering terminated
a)
Any filing fee due:
b)
Any information required to be filed to comply with orders of, or commitments to, the Office
I,
(Name)
(Organization)
do solemnly swear that I have read the foregoing report and all exhibits in connection therewith, and, in the case where I am
executing this report as a principal of the Issuer, that I have knowledge and that the facts and representations contained therein are
true to the best of my knowledge and belief; and, in the case where I am executing this report for other than the Issuer, that I have
fully set forth the sources of the i
nformation contained in the report and exhibits thereto, and that suc
h sources are reliable to the
best of my knowledge and belief.
Signature
Date signed
RETURN TO:
Office of Financial and Insurance Services
Securities Section
P.O. Box 30701
Lansing, MI 48909-8201
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