Oklahoma Accredited Investor Exemption Supplemental Information Form
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2Oklahoma Accredited Investor Exemption
Supplemental Information Form
OKLAHOMA DEPARTMENT OF SECURITIES
120 N. Robinson, Suite 860
Oklahoma City, OK 73102
(405) 280-7700
The Oklahoma Accredited Investor Exemption (“OAIE”) was originally adopted by an order of the Administrator of the
Oklahoma Department of Securities (the “Department”) on March 8, 1999. Effective July 1, 2004, the OAIE is set forth in
660:11-11-52 of the Rules of the Oklahoma Securities Commission and the Administrator of the Department of Securities,
a part of the Oklahoma Administrative Code ("Rules"). 660:11-11-52 was finally adopted under the authority of Section 2-
103 of the Oklahoma Uniform Securities Act of 2004 (OUSA), also effective July 1, 2004. This form is supplemental to,
and must be filed with the Department in addition to, the NASAA Model Accredited Investor Exemption Uniform Notice of
Transaction (the “Uniform Notice”) by any person intending to rely upon such exemption for offers and sales subject to
OUSA. The notice must also include a consent to service of process [Form U-2 and (if applicable) Form U-2A], a copy of
the general announcement as specified in the rule, and a fee as set forth in Section 1-612.A.12 of OUSA. Such filing
must be made no later than 15 days after the first sale of securities subject to the OUSA.
PART A
1. Issuer Name: ______________________________________________________
2. Type of Filing:
New Filing
Amendment
PART B
Enter the information requested for the following:
•
Each promoter of the issuer, if the issuer has been organized in the past five years;
•
Each beneficial owner having power to vote or dispose, or direct the vote or disposition of, 10% or more of a class of equity securities of the issuer;
•
Each executive officer or director of corporate general and managing partners of partnership issuers;
•
Each executive officer or director of corporate managers of limited liability companies;
•
Each individual general or managing partner of partnership issuers; and
•
Each individual manager of limited liability company issuers.
Check Box(es) that Apply:
Promoter
Beneficial Owner
Executive Officer
Director
General or Managing Partner
Manager
Other (Explain)
Full Name (Last name first, if individual):
Company Name:
Business or Residence Address (Number and Street, City, State, ZIP Code):
Phone:
Explanation (if necessary):
Check Box(es) that Apply:
Promoter
Beneficial Owner
Executive Officer
Director
General or Managing Partner
Manager
Other (Explain)
Full Name (Last name first, if individual):
Company Name:
Business or Residence Address (Number and Street, City, State, ZIP Code):
Phone:
Explanation (if necessary):
Check Box(es) that Apply:
Promoter
Beneficial Owner
Executive Officer
Director
General or Managing Partner
Manager
Other (Explain)
Full Name (Last name first, if individual):
Company Name:
Business or Residence Address (Number and Street, City, State, ZIP Code):
Phone:
Explanation (if necessary):
(Use blank sheet, or use additional copies of this sheet, as necessary.)
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