Form Com 4508 - Notice Of Proposed Public Offering Solely To Accredited Investors

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File
Number
nd
77 South High Street, 22
Floor
Columbus, Ohio 43215-6131
Telephone: (614) 644-7381
Form 3-Y
Notice of Proposed Public Offering Solely to
Accredited Investors
Model Accredited Investors Exemptions
1707.03(Y)
Claimant Must Not fill
Checked
In.
Date
By
Notation
Division Record --
Fee ($100)
Received
Prior filings
checked
Examined as to form
Amendment requested
Record
Made
Examination
Requested
Exemption 3-Y (Claimant Must Not Fill In.
(File)
(Date)
(Amount)
(Description)
(Price)
Instructions:
This form to be used only for any offer and sale of securities made solely to accredited investors, as defined in Rule 501 of regulation
D under the Securities Act of 1933, made in reliance on the exemption under R.C. 1707.03(Y). This form, with a $100 filing fee and
nd
the required exhibits, must be submitted to the Ohio Division of Securities, 77 S. High Street, 22
Floor, Columbus, OH 43215-6131
within fifteen days of the first use of a general announcement of the offering. Note: This form may not be filed in connection with
offerings exempt under R.C. 1707.03(Q), (W) or (X).
1.
Issuer's full
name
Payer’s Federal Tax Identification Number
2.
Issuer's
Address
(Street)
(City, State, Zip)
(Phone No.)
3.
State of
Date of incorporation/formation
incorporation/formation
Type of Entity
(Corporation, Partnership, etc.)

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