Form Fis 0568 - Confidential Report Form

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FIS 0568 (6/04) Office of Financial and Insurance Services
Confidential Report Form
INSTRUCTIONS: File this form to claim exemption from registration pursuant to Section 402(b)(9) of
the Michigan Uniform Securities Act if a commission is paid or given for soliciting any purchaser in
Michigan. All commissions that are paid shall be reflected on the books and records of the Broker-
Dealer, and shall be fully disclosed in writing to each prospective purchaser. The Report may be filed
by the Issuer or Broker-Dealer and must be signed by an authorized agent or representative.
Attach a list of the names and addresses of all Michigan purchasers.
RETURN TO:
This form is issued under Act 265, PA 1964, as
amended. This form must be completed for exemption
Office of Financial and Insurance Services
from registration under Section 402(b)(9) of the Act if
commissions are paid. Failure to file will disqualify the
P.O. Box 30701
issuer from utilizing this exemption.
Lansing, MI 48909-8201

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