Form Sra - Addendum To Business Organization And Registration Forms Statement Of Compliance With New Hampshire Securities Laws

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Form SRA – Addendum to Business Organization and Registration Forms
Statement of Compliance with New Hampshire Securities Laws
Part I – Business Identification and Contact Information
Business Name: ___________________________________________________________________________________
Business Address (include city, state, zip): ______________________________________________________________
Telephone Number: (______) _________________________ E-mail:________________________________________
Contact Person:___________________________________________________________________________________
Contact Person Address (If Different):__________________________________________________________________
Part II – Check ONE of the following items in Part II If more than one item is checked, this form will be rejected.
[PLEASE NOTE: Most small businesses registering in New Hampshire qualify for the exemption in Part II, Item 1 below.
However, you must insure that your business meets all of the requirements spelled out in A), B) and C)]:
1. ____
Ownership interests in this business are exempt from the registration requirements of the state of New Hampshire
because the business meets ALL of the following three requirements:
A) This business has 10 or fewer owners; and
B) Advertising relating to the sale of ownership interests has not been circulated; and
C) Sales of ownership interests – if any – will be completed within 60 days of the formation of this business.
2. ____
This business will offer securities in New Hampshire under another exemption from registration or will notice file
for federal covered securities. Enter the citation for the exemption or notice filing claimed - ___________________.
3. ____
This business has registered or will register its securities for sale in New Hampshire. Enter the date the registration
statement was or will be filed with the Bureau of Securities Regulation - _____________.
4. ____
This business was formed in a state other than New Hampshire and will not offer or sell securities in New
Part III – Check ONE of the following items in Part III:
1. ____
This business is not a New Hampshire corporation or limited partnership. (ALL LLC's should check this item.)
2. ____
This business is a New Hampshire corporation or limited partnership and the articles of incorporation or certificate
of limited partnership states whether capital stock or interests will be sold or offered for sale.
Part IV – Certification of Accuracy
(NOTE: The information in Part IV must be certified by: 1) all of the incorporators of a corporation to be formed; or 2) an
executive officer of an existing corporation; or 3) all of the general partners or intended general partners of a limited
partnership; or 4) one or more authorized members or managers of a limited liability company; or 5) one or more authorized
partners of a registered limited liability partnership or foreign registered limited liability partnership.)
I (We) certify that the information provided in this form is true and complete. (Original signatures only)
Name (print): _________________________________ Signature: __________________________________
Name (print): _________________________________ Signature: __________________________________
Name (print): _________________________________ Signature: __________________________________
Date: _____________________
Rev. 4/04


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