Form Ksc-1 - Sales Report Or Renewal Application

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OFFICE OF THE KANSAS SECURITIES COMMISSIONER
CE OF THE KANSAS SECURITIES COMMISSIONER
Form KSC-1
Form KSC-1
SALES REPORT or RENEWAL APPLICATION
Please indicate the purpose of filing this form by check-mark or "X" below:
To report the amount of securities sold in Kansas during the registration period as required by K.S.A.
17-12a305(i) and K.A.R. 81-4-1(f). Please complete items 1 through 4 below and if an additional
registration fee is required as explained in the NOTE to item 4, please enter the fee amount under item
6 and remit; or
To extend the registration of securities for an additional year and report the amount of securities sold in
Kansas during the current registration period as authorized by K.S.A. 17-12a305(h) and (i) and K.A.R.
81-4-1(d). Please complete all items below and remit the total fee determined under item 6.
1. Issuer Name and Address:
KSC File No.
.
Effective Date
.
2. Correspondent Name, Address and Phone No.:
3. Description of Securities:
4. Amount of securities sold in Kansas during one-year registration period
$
.
Amount of securities registered in Kansas
$
.
Amount sold in excess of amount registered in Kansas
$
.
NOTE:
If the amount of securities sold in Kansas during the previous registration period exceeds the
amount registered in Kansas as reported above, then an additional registration fee at 0.05% of the
excess amount sold in Kansas may be required up to the maximum annual fee of $1,500 specified by
K.A.R. 81-4-1(a) (the total of original and additional registration fees is limited to $1,500).
5. Aggregate offering price of securities to be offered in Kansas during extended year of registration:
Offering Price
No. of
Aggregate
Per Share/Unit
Shares/Units
Offering Price
6. Registration fee at 0.05% of the aggregate offering price above (up to $1,500):
$
.
Additional fee if required for previous registration (see NOTE under 4 above):
$
.
Total registration fees filed with this application
$
.
(Minimum fee = $100 and Maximum fee = $1,500 per year of registration)
7. A CURRENT PROSPECTUS WITH CURRENT FINANCIAL STATEMENTS IS REQUIRED WITH THIS
RENEWAL APPLICATION, unless filed with a recent amendment (explain if not filed).
___________________________
_______________________________
___/___/____
Representative of Issuer
Signature
Date
(July-09)

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