Notice Of Transaction Pursuant To Corporations Code Section 25102(F) - California Commissioner Of Corporations

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(Department of Corporations Use Only)
Department of Corporations File No., if any:
Fee Paid $ ______________________
___________________________________
Receipt No. _____________________
Insert File number(s) of Previous Filings
Before the Department if any.
FEE: $25.00 $35.00 $50.00 $150.00
Circle the appropriate amount of fee. See Corporations Code Section 25608(c), and note below.
[Note: Pursuant to Corporations Code Section 25608.3 (See Commissioner's Release No. 115-C dated December 6, 2001), the maximum filing
fee associated with the Corporations Code Section 25102(f) notice has been reduced from $300 to $150, effective January 1, 2002]
COMMISSIONER OF CORPORATIONS
STATE OF CALIFORNIA
NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102(f)
A.
Check One:
Transaction under
( ) Section 25102(f)
( ) Rule 260.103
1.
Name of Issuer:_____________________________________________________________________
2.
Address of Issuer: ___________________________________________________________________
Street
City
State
ZIP
Mailing Address: ____________________________________________________________________
Street
City
State
ZIP
3.
Area Code and Telephone Number: _____________________________________________________
4.
Issuer's state (or other jurisdiction) of incorporation or organization: ____________________________
5.
Title of class or classes of securities sold in transaction: _____________________________________
__________________________________________________________________________________
6.
The value of the securities sold or proposed to be sold in the transaction, determined in accordance with
Corporations Code Sec. 25608(g) in connection with the fee required upon filing this notice, is (fee based
on amount shown in line (iii) under Total Offering):
California
Total Offering
(a)(i)
in money
$ ______
$ _________
(ii)
in consideration other than money
$ ______
$ _________
(iii)
total of (i) and (ii)
$ ______
$ _________
(b)
( ) Change in rights, preferences, privileges or restrictions of or on outstanding securities.
($25.00 fee) (See Rule 260.103.)
7.
Type of filing under Securities Act of 1933, if applicable: ___________________________________
________________________________________________________________________________
8.
Date of Notice: ___________
_________________________________________
Issuer
( )
Check if issuer already has a consent to service _________________________________________
of process on file with the Commissioner.
Authorized Signature on behalf of Issuer
_________________________________________
Print name and title of signatory
Name, Address and Phone Number of contact person:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Instruction: Each issuer (other than a California Corporation) filing a notice under Section 25102(f) must file a
Consent to service process (Form 260.165), unless it already has a consent to service on file with the Commissioner.
260.102.14(c) Rev. 01/02

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