Quarterly And/or Final Report Of Sales Of Securities Form - Division Of Securities

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SD EForm - 1436
V1
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DIVISION OF SECURITIES
STATE OF SOUTH DAKOTA
445 E Capitol Avenue
Pierre, South Dakota 57501
QUARTERLY AND/OR FINAL REPORT OF SALES OF SECURITIES
OUR FILE NUMBER:____________________________ DATE OF EFFECTIVE REGISTRATION:_______________
NAME OF ISSUER:_________________________________________________________________________________
DESCRIPTION OF ISSUE:___________________________________________________________________________
AGGREGATE DOLLAR AMOUNT REGISTERED IN SOUTH DAKOTA: $__________________________________
UNSOLD BALANCE AT THE BEGINNING OF REPORTING PERIOD: $____________________________________
AMOUNT REGISTERED THIS PERIOD: $_____________________________________________________________
TOTAL AVAILABLE FOR SALE THIS PERIOD: $_______________________________________________________
AMOUNT SOLD THIS REPORTING PERIOD: $_________________________________________________________
AMOUNT UNSOLD AT END OF THIS REPORTING PERIOD (balance): $___________________________________
RATIO OF COMMISSIONS AND UNDERWRITING EXPENSES TO AGGREGATE AMOUNT SOLD:___________
THIS REPORT COVERS THE PERIOD ENDING:________________________________________________________
COMPLETE THE BOTTOM PORTION OF THIS REPORT ONLY IF IT APPLIES:
Please check the appropriate box ( ):
( ) Registration has been COMPLETED and no further offers or sales will be made in connection with this offering and
sale of securities.
( ) It is requested that the unsold balance of $__________________________________ (aggregate dollar amount) be
renewed for an additional period of one (1) year. In support of this request, we enclose the following:
1. Renewal fee of $100.00 payable to the South Dakota Division of Securities.
2. An updated prospectus containing a balance sheet and a profit and loss statement as of a date not
more than ninety (90) days prior to the date of renewal.
EXECUTED THIS_________________DAY OF____________________________, 20____ AT___________________
(Please type or print)
_________________________________________
NAME OF ISSUER OR UNDERWRITER
_________________________________________
SIGNATURE AND OFFICIAL CAPACITY
PRINT FOR MAILING
CLEAR FORM

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