Form 14-25v - Accredited Investor Exemption Uniform Notice Of Transaction printable pdf download

Form 14-25v - Accredited Investor Exemption Uniform Notice Of Transaction

State Of Utah

Form 14-25v

DEPARTMENT OF COMMERCE

(Rev. 12/15/2011)

Page 1 of 2

Division of Securities

Accredited Investor Exemption

Uniform Notice of Transaction

Form 14-25v

Notice of Sale of Securities pursuant to Accredited Investor Exemption

1. Issuer:

Name: __________________________________________________________________

Address: _______________________________________________________________

Telephone Number: ______________________________________________________

2. Form of Organization: (check one)



Corporation

Unincorporated Association

Limited Liability Company



Limited Partnership

Other (specify) ____________________________________

Issuer’s state or jurisdiction of Incorporation or Organization: ______________________

Date of Incorporation or Organization: ________________________________________

3. Officers and Directors: (or persons acting in a similar capacity)

Names, Business Addresses, and Business Phone Numbers

________________________________________________________________________

4. This Offering:

Number of

Aggregate Dollar

Description of

Price per

Securities to be

Amount of

Security

Offered

Offering

Debt

Equity

(Common or Preferred)

Convertible Security

Partnership Interests

Other (specify)

Form 14-25v - Accredited Investor Exemption Uniform Notice Of Transaction