Fillable Form IP-W: Crowdfunding Internet Portal Withdrawal of Registration (Illinois Secretary of State)

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Form IP-W: Crowdfunding Internet Portal Withdrawal of Registration (Illinois Secretary of State)

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Illinois Secretary of State
Securities Department
6
9 W. Washington St., Ste. 1220
Chicago, IL 60602 • 312-793-3384
Crowdfunding@ilsos.net
Form IP-W
Crowdfunding Internet Portal
Withdrawal of Registration
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 City, State, ZIP
2. List the date the Internet Portal ceased business or withdrew its registration request: __________________________________________
3. List the Location of Books and Records after Registration Withdrawal:
________________________________________________________________________________________________________________
Name of Custodian
___________________________________________________ ______________________________________________________
Street Address City, State, ZIP
___________________________________________________ ______________________________________________________
Email Address Telephone Numbers
4. Briefly describe the books and records kept at this location: ______________________________________________________________
________________________________________________________________________________________________________________
5. Is the portal now the subject of or named in any investment or business related:
Investigation?
n
yes
n
no
Investor related complaint?
n
yes
n
no
Private civil litigation?
n
yes
n
no
Regulatory Action, Arbitration, or other criminal or civil proceeding?
n
yes
n
no
Printed by authority of the State of Illinois. April 2016 — 1 — SEC 347
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Execution:
The undersigned represents that he or she has executed this form on behalf of the named Internet Portal and that all information contained
h
erein is current, accurate and complete. The undersigned and the named portal further represent that the portal’s books and records will be
preserved and available for inspection as required by law.
____________________________________ _____________________________________________________________________
Date Name of Representative of Internet Portal
____________________________________ _____________________________________________________________________
Date Signature of Representative of Internet Portal
____________________________________ _____________________________________________________________________
Date Title
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Form IP-W: Crowdfunding Internet Portal Withdrawal of Registration (Illinois Secretary of State)

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Completed 28 August 2020

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