Form Si-Ptsupp - Corporate Disclosure Statement - State Of California Secretary Of State
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1
2State of California
Kevin Shelley
Secretary of State
CORPORATE DISCLOSURE STATEMENT
Supplement to Statement of Information
(Domestic Stock and Foreign Corporations)
This Space For Filing Use Only
IMPORTANT – READ INSTRUCTIONS BEFORE COMPLETING THIS FORM
1.
CORPORATE NAME:
INDEPENDENT AUDITOR
(See explanation in instructions.)
2.
NAME OF THE INDEPENDENT AUDITOR:
3.
DATE OF THE LAST REPORT PREPARED FOR THE CORPORATION BY THE INDEPENDENT AUDITOR:
(ATTACH A COPY OF THE LAST REPORT TO THIS STATEMENT)
4.
DESCRIPTION OF ANY OTHER SERVICES PERFORMED BY THE INDEPENDENT AUDITOR (See Instructions):
DIRECTORS AND EXECUTIVE OFFICERS
(See explanation in instructions.)
ANNUAL
5.
NAMES OF DIRECTORS
SHARES
OPTIONS
BANKRUPTCY
FRAUD
COMPENSATION
1)
YES
NO
YES
NO
2)
YES
NO
YES
NO
3)
YES
NO
YES
NO
4)
YES
NO
YES
NO
5)
YES
NO
YES
NO
IF THE CORPORATION HAS ADDITIONAL DIRECTORS, COMPLETE ITEM B OF THE ATTACHMENT (FORM SI-PTSUPPA).
ANNUAL
6.
NAMES OF EXECUTIVE OFFICERS
SHARES
OPTIONS
BANKRUPTCY
FRAUD
COMPENSATION
1)
YES
NO
YES
NO
2)
YES
NO
YES
NO
3)
YES
NO
YES
NO
4)
YES
NO
YES
NO
5)
YES
NO
YES
NO
LOANS TO MEMBERS OF THE BOARD OF DIRECTORS
(See explanation in instructions.)
7.
NAMES OF DIRECTORS
DESCRIPTION OF LOAN (INCLUDING AMOUNT AND TERMS)
1)
2)
3)
4)
5)
IF THE CORPORATION HAS MADE ADDITIONAL LOANS TO DIRECTORS, COMPLETE ITEM C OF THE ATTACHMENT (FORM SI-PTSUPPA).
ADDITIONAL STATUTORY DISCLOSURES
8.
HAS THE CORPORATION FILED BANKRUPTCY WITHIN THE PREVIOUS 10 YEARS?
YES
NO
HAS THE CORPORATION VIOLATED ANY FEDERAL SECURITY LAWS OR ANY SECURITY OR BANKING PROVISION OF
9.
CALIFORNIA LAW DURING THE PREVIOUS 10 YEARS FOR WHICH THE CORPORATION WAS FOUND LIABLE IN AN ACTION
YES
NO
BEFORE A FEDERAL OR STATE COURT OR REGULATORY AGENCY OR A SELF-REGULATORY ORGANIZATION IN WHICH A
JUDGEMENT OVER TEN THOUSAND DOLLARS ($10,000) WAS ENTERED?
10. BY SUBMITTING THIS CORPORATE DISCLOSURE STATEMENT TO THE SECRETARY OF STATE, THE CORPORATION CERTIFIES THE
INFORMATION CONTAINED HEREIN, INCLUDING ANY ATTACHMENTS, IS TRUE AND CORRECT.
TYPE OR PRINT NAME OF OFFICER OR AGENT
TITLE
DATE
SI-PTSUPP (REV 04/2003)
APPROVED BY SECRETARY OF STATE
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