Ny Form 99 - Notification Filing Page 2
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INFORMATION ABOUT OFFERING
Total Offering Amount (maximum) $
Minimum Offering Amount $_
Type of Security Offered (brief description):
Enclosures (add additional sheets if necessary):
□ Copy of Consent to Service of Process (U-2) (original to New York State Department of State, Albany NY)
□ Offering Documents
□ Confidential Attachment to Form 99
□ Further information as to ☐ issuer ☐ affiliated persons
□ Form D: ☐ copy “as filed” with the S.E.C ☐ “as filed” copy will follow
□ Form 1-A
□ Theatrical Venture Amendment - Required Supplemental Information
C. INFORMATION ABOUT ISSUER, PRINCIPALS AND CONTROLLING PERSONS
• As to issuer:
1.
Is issuer subject to or a respondent in any legal action for, any injunction, cease-and-desist order or order or
stipulation to desist or refrain from any act or practice relating to the offering of securities in New York or any
☐ Yes
☐ No
other jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
(a) Has issuer ever been convicted of or pleaded guilty to any crime (i) involving any fraud, or
(ii) relating to any financial transaction or handling of funds of another person, or
□ No
(iii) pertaining to any dealings in any securities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Yes
(b) Is issuer now a defendant in any such criminal proceeding? . . . . . . . . . . . . . . . . . . . . . ☐ Yes
□ No
• As to each Principal*, each Controlling Person, and any Sponsoring Entity of issuer:
3.
Is any one of the above subject to or a respondent in any legal action for, any injunction, cease-and-desist
order or order or stipulation to desist or refrain from any act or practice relating to the offering of securities in
New York or any other jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Yes
☐ No
4.
(a) Has any one of the above ever been convicted of or pleaded guilty to any crime (i) involving any fraud, or
(ii) relating to any financial transaction or handling of funds of another person, or
(iii) pertaining to any dealings in any securities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Yes
☐ No
(b) Is any one of the above now a defendant in any such criminal proceeding ? . . . . . . . . . ☐ Yes
☐ No
5.
Has any of the above ever been suspended or expelled from membership in any securities or commodities
exchange or association or had a securities or commodities license or registration denied, suspended or
revoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Yes
☐ No
6.
Has any of the above been a controlling person or sponsor with respect to any issuer which engaged in a
distribution of securities or any public offering within the past three (3) years? . . . . . . . . . ☐Yes ☐ No
If the answer to any of the above is “yes”, give material facts on an attached sheet.
*
Capitalized terms are defined in Section E of Form 99.
IPB/REF099 - (rev. 7/201 5)
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