Fillable Form IP Initial Filing ($300 fee): Crowdfunding Internet (Illinois Secretary of State)

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Form IP Initial Filing ($300 fee): Crowdfunding Internet (Illinois Secretary of State)

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Illinois Secretary of State
Securities Department
69 W. Washington St., Ste. 1220
Chicago, IL 60602 • 312-793-3384
Crowdfunding@ilsos.net
Form IP
Crowdfunding Internet
Portal Registration
(Mark one)
Form IP Initial Filing ($300 fee)
Amendment to Form IP ($300 fee)
Form IP Renewal Filing ($300 fee)
1. Internet Portal Information
________________________________________________________________________________________________________________
Name of Applicant
________________________________________________________________________________________________________________
Name(s) under which business is conducted (if different from Applicant Name)
_____________________________________________________ _____________________________________________________
Street Address City, State, ZIP
_____________________________________________________ _____________________________________________________
Website Address Email Address
_____________________________________________________ _____________________________________________________
Website (URL) Telephone Number
_____________________________________________________
FEIN Number
2. Contact to whom Communications regarding this Form should be directed:
_____________________________________________________ _____________________________________________________
Name Street Address
_____________________________________________________ _____________________________________________________
Telephone Number City, State, ZIP
_____________________________________________________
Email Address
3. Form of organization, date and state of formation: _______________________________________________________________________
________________________________________________________________________________________________________________
Printed by authority of the State of Illinois. April 2016 — 1 — SEC 348
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4. Owners and Control Persons
In the chart that follows, list the names of the following persons:
a. Each officer, director, or other person having the power, directly or indirectly, to direct the management or policies of the Applicant,
whether by contract or otherwise; and
b. Each person that owns, beneficially owns, has the right to vote, or has the power to sell or direct the sale of 20% or more of a class of
the Issuer’s voting securities. For purposes of this provision, a person beneficially owns any securities: (i) owned by his/her child,
stepchild, grandchild, parent, stepparent, grandparent, spouse, sibling, mother-in-law, father-in-law, son-in- law, daughter-in-law,
brother-in-law, or sister-in-law, sharing the same residence; or (ii) that he/she has the right to acquire, within 60 days, through the
exercise of any option, warrant, or right to purchase the security.
Complete the Title/Status column by entering predecessor or board/management titles; status as partner, trustee, sole proprietor, elected
manager, shareholder, or member; and for shareholders or members, the class of securities owned (if more than one is issued).
Enter an ownership code if applicable. Ownership codes are:
A - Less than 20% B - 20% or more but less than 50%
C - 50% or more but less than 75% D - 75% or more
Full Name Title/Status Ownership Code
5. Disclosure Information
By filing this Crowdfunding Internet Portal Registration, the applicant hereby represents that the
Internet Portal, its
predecessors, any
affiliated Internet Portal, and each director, officer, and control person:
1. has not within the last five years, filed a registration statement which is the subject of a currently effective registration stop order
entered by any state securities administrator or the United States Securities and Exchange Commission; or
2. has not within the last five years, been convicted of any criminal offense in connection with the offer, purchase, or sale of any security,
or involving fraud or deceit; or
3. is not currently subject to any state or federal administrative enforcement order or judgment, entered within the last five years, finding
fraud or deceit in connection with the purchase or sale of any security; or
4. is not currently subject to any order, judgment, or decree of any court of competent jurisdiction, entered within the last five years,
temporarily, preliminarily, or permanently restraining or enjoining such party from engaging in or continuing to engage in any conduct or
practice involving fraud or deceit in connection with the purchase or sale of any security.
6. Consent to Service of Process. Attach completed Form U-2 Uniform Consent to Service of Process.
7. The undersigned represents that the applicant is familiar with the conditions that must be satisfied to be entitled to the Intrastate Crowd -
funding Internet Portal Registration. The Applicant has read this Form and knows the contents to be true and has duly caused this Form to
be signed on its behalf by the undersigned duly authorized person.
The undersigned affirms that to the best of his or her knowledge, information, and belief the statements made on this form are true.
_____________________________________________________ _____________________________________________________
Date Name of Representative of Internet Portal
_____________________________________________________ _____________________________________________________
Signature of Representative of Internet Portal
_____________________________________________________ _____________________________________________________
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Form IP Initial Filing ($300 fee): Crowdfunding Internet (Illinois Secretary of State)

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Completed 28 August 2020

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