Form Ofr-S-10-91 - Report Of Sales Of Securities And Use Of Proceeds Therefrom printable pdf download

Form Ofr-S-10-91 - Report Of Sales Of Securities And Use Of Proceeds Therefrom

STATE OF FLORIDA

OFFICE OF FINANCIAL REGULATION

REPORT OF SALES OF SECURITIES AND USE OF PROCEEDS THEREFROM

For Period From

1. Name of issuer:

2. Permit No.:

3. Name of Underwriter, if any:

(a) Date Offering commenced:

(b) If offering has not commenced, state reasons briefly:

(a) Date offering completed, if completed:

(b) If offering was terminated prior to completion, explain briefly:

(a) Total amount of securities registered. Give the title, number of shares, offering price and

aggregate sales amount.

(b) Amount of securities sold from commencement of offering to date:

7. Total amount received from public from commencement of offering to date: $

8. We report herewith sales of

for the

______

period ended

Date Last

Amount Last

Amount

Registered

Sold for =

Unsold

in Florida

Period

Balance

If offering has been completed, show amount sold in Florida:

9. Furnish a reasonably itemized statement of the use made of the proceeds from the sale of the

securities from the commencement of the offering to date.

Instructions:

1. State separately: (a) underwriting discounts and commissions; (b) expenses paid to or for the

underwriters; (c) other expenses of the offering paid to date by or for the account of the issuer; and

(d) each other purpose for which a substantial amount of the proceeds has been used.

2. As to each category of expenditures, state separately: (a) payments to directors, officers and affiliates;

and (b) payments to other persons.

3. If any of the proceeds were used for any purpose not indicated in the prospectus, so state and give

the reason for deviating from the use of proceeds as set forth in the prospectus. If all of the proceeds

were used for the purpose indicated in the prospectus, so state.

(Issuer)

Date:

By: ____________________________________________________

OFR-S-10-91, Report of Sales of Securities and Use of Proceeds Therefrom, Effective 11/22/10, Incorporated by Reference in

Rule 69W-301.002, F.A.C.

Form Ofr-S-10-91 - Report Of Sales Of Securities And Use Of Proceeds Therefrom

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