Notification Of Claim Of Exemption - Washington Deptartment Of Financial Institutions
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5State of Washington
NOTIFICATION OF CLAIM OF EXEMPTION
Dept. of Financial Institutions
Pursuant to RCW 21.20.320(9), WAC 460-44A-504, and
Securities Division
Securities and Exchange Commission Rule 147
P.O. Box 9033
Olympia, WA 98507-9033
(360) 902-8760
Intentional misstatements or omissions of fact constitute criminal
violations. See RCW 21.20.400.
Item 1. Issuer’s Identity
Name of Issuer
Previous Name(s)
Entity Type (Select one)
None
Corporation
Limited Partnership
Jurisdiction of Incorporation/Organization
Limited Liability Company
General Partnership
Year of Incorporation/Organization:
Business Trust
Over Five Years Ago
Other (Specify)
Within Last Five Years (specify year)
Yet to Be Formed
Item 2. Principal Place of Business
Street Address Line 1
Street Address Line 2
City
State/Province/Country
ZIP/Postal Code
Phone No.
Item 3. Contact Person
Directions: Provide the name and contact information for the person to contact with questions about the filing of this notice.
Last Name
First Name
Firm Name
Street Address Line 1
Street Address Line 2
City
State/Province/Country
ZIP/Postal Code
Phone
Fax
E-mail
Item 4. Related Persons
Directions: Provide contact information for all executive officers, directors, promoters and beneficial owners of 10% or more of a
class of the issuer’s equity securities.
Last Name
First Name
Middle Name
Street Address Line 1
Street Address Line 2
City
State/Province/Country
ZIP/Postal Code
Relationship(s):
Executive Officer
Director
Promoter
Beneficial Owner
Identify additional related persons by checking this box
and attaching Item 4 Continuation Page(s).
Form Rev. 3/21/2012
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