Notice Of Exchange Transaction Pursuant To Corporations Code Section 25103(H) - Department Of Corporations
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1
2(Department of Corporations
DEPARTMENT OF CORPORATIONS
Use Only)
FILE No., if any:
Fee Paid $ ___________________
_____________________________ _
(Insert File Numbers(s) of Previous
Receipt No. __________________
Filings Before the
Department, If Any)
FEE:
$600
(See Corporations Code Section 25608(z))
COMMISSIONER OF CORPORATIONS
STATE OF CALIFORNIA
NOTICE OF EXCHANGE TRANSACTION
PURSUANT TO CORPORATIONS CODE SECTION 25103(h)
1.
Name of Acquiring Entity: __________________________________
2.
(a)
Address of Acquiring Entity:
_______________________________________________________
Street
City
State
ZIP
(b)
Mailing Address:
_______________________________________________________
Street
City
State
ZIP
(c)
Area Code and Telephone Number: _______________________
3.
Acquiring Entity's state (or other jurisdiction) of
incorporation or organization: __________________________
4.
(a)
Name of Entity to be Acquired:
_______________________________________________________
(b)
State (or other jurisdiction) of incorporation or
organization of Entity to be Acquired: ________________
5.
The exchange of securities meets the requirements of (check one):
[ ]
Section 25103(h)(1)(A) of the Code.
[ ]
Section 25 103(h)(1)(B) of the Code, and the state of
incorporation or organization is _____________________, or
the form of organization is _______________________.
6.
Type of filing under the Securities Act of 1933, if
applicable:
_______________________________________________
7.
Date of Notice: __________
_________________________________
Acquiring Entity
(
) Check if Acquiring
Entity has a consent
_________________________________
to service of process
Authorized Signature on
on file with the
Behalf of Acquiring Entity
Commissioner.
_________________________________
Print Name and Title of Signatory
25103(h) (Revised 5/97)
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