Form 500-3 - Year End Securities Sales Report
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1Nevada Form 500-3
ROSS MILLER
Secretary of State
555 East Washington Ave., #5200
Year End
Las Vegas, Nevada 89101
Phone (702) 486-2440
Securities Sales Report
Fax (702) 486-2452
Website:
ABOVE SPACE FOR OFFICE USE ONLY
Date:
1. The undersigned hereby files a fiscal year end securities report pursuant to NRS 90.500 paragraph 3.
2. The following information is submitted:
Name of Issuer
Address of Issuer
City
State
Zip Code
Street or Mailing Address
Fiscal Year End:
Nevada Securities Division File No.:
3. I understand that this form must be accompanied by a filing fee of 0.2% of the maximum aggregate offering
price at which the registered securities are to be offered in this State, but no less than $700.00 or more than
$5,000.00. I also understand that this year end fee is in addition to whatever fee was filed with the initial
registration statement.
a.
The aggregate sale price of the securities sold under this registration
USD $
to persons in Nevada during the previous fiscal year was:
b.
The following fee is enclosed in the form of a check payable to
USD $
SECRETARY OF STATE, SECURITIES DIVISION:
4. The following information is submitted:
Effective date:
Expiration date:
Aggregate amount available for sale in Nevada: USD $
Total amount sold in Nevada: USD $
5. I understand that no acknowledgment of this filing will be made unless one additional copy of this
notice and a self-addressed, stamped envelope are submitted with this form.
6. Submitted by:
Name of Submitter
Address of Submitter
Street Address
City
State
Zip Code
Telephone:
NOTE: In order for your report to be processed, this form must be filled out completely. Incomplete forms will be
returned.
Nevada Secretary of State Securities Form 500-3
Revised 12-23-10
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