Form Dr 1830 - Material Advisor Disclosure Statement For Colorado Listed Transaction

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dr 1830 (3/1/10)
CoLorADo DepArTMenT oF revenue
1375 ShErMAN STrEET
DENvEr CO 80261
Material Advisor Disclosure Statement
For Colorado Listed Transaction
1. Material Advisor’s Name
Identifying number
l;k;lk;lk
;lk;lk;lk
Address
Apt/Suite number
City
State
ZIP
;lk;lk;l
;k;lk;l
;lkl;k;lk
;lkkl;k;
;lk;klkl;
Contact person name (last name, first name, middle name)
Title
Telephone number
;lk;lk;lk
(
)
k;k;lk;
;k;kll
If you are a party to a designation agreement, identify the other parties.
Identifying number (if known)
Name
kl;;klk;l
;klkl;
Address
Apt/Suite number
City
State
ZIP
k;l;kl;kl
;lkk;l
;klkl;
k;l;lk
;klkl;
Contact name
Telephone number
(
)
;lkk;klkl;
k;lkl;;lk
2. Owner’s Name
Identifying Number
kl;kl;
k;lkl;
Address
Apt/Suite number
City
State
ZIP
;klk;l
;klk;l
;klk;l
kl;kl;
kl;kl;
Contact Person
Title
Telephone number
;lkk;klkl;
(
kl;k;l
)
k;l;kl
3. Captive Entity’s Name
Identifying Number
kl;kl
;klkl;
Address
Apt/Suite number
City
State
ZIP
k;lk;l
k;lkl;
k;l
;kl
;kl
Contact Person
Title
Telephone number
(
)
kl;
k;l
k;l
4. Provide a brief description of the material aid, assistance, or advice you provide.
kl;
_______________________________________________________________________________________________________________________
k;l
_______________________________________________________________________________________________________________________
k;l
_______________________________________________________________________________________________________________________
;lk
_______________________________________________________________________________________________________________________
;kl
_______________________________________________________________________________________________________________________
kl;
_______________________________________________________________________________________________________________________
;lk
_______________________________________________________________________________________________________________________
lk;
_______________________________________________________________________________________________________________________
kl
_______________________________________________________________________________________________________________________
kl;
_______________________________________________________________________________________________________________________
;lk
_______________________________________________________________________________________________________________________
kl;
_______________________________________________________________________________________________________________________
kl;
I declare that I have examined this statement and, to the best of my knowledge and belief, it is true, correct, and complete.
Signature of Material Advisor
Date
Title
k;l
k;l
Print Name
kl;

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