Fillable Information Regarding the Filing of Reports of Sale (Illinois Secretary of State)

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Information Regarding the Filing of Reports of Sale (Illinois Secretary of State)

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Illinois Secretary of State
Securities Department
421 E. Capitol Ave., 2nd Floor
Springfield, IL 62701
217-782-2256
Information Regarding the
Filing of Reports of Sale Under
Section 4.G of The Illinois
Securities Law of 1953
• To confirm the filing of a Report of Sale, a pre-addressed stamped envelope and a duplicate copy of the Report of Sale form must be
included with the filing.
• If the Report of Sale is filed more than 12 months after the date of the first sale, a $100 penalty fee is required in addition to the $100 filing fee.
• If sales are being reported for more than 12 months, a separate Report of Sale form and $100 filing fee must be submitted for each
consecutive 12-month period. A $100 penalty fee is required for each late filing.
• Make checks payable to Illinois Secretary of State. The Report of Sale is deemed to be filed with the Secretary of State when the filing fee
(and penalty fee, if any) is paid and the information required on the report is complete.
• The text of Section 4.G of The Illinois Securities Law of 1953, as amended, and Sections 130.440 and 130.442 of the Rules, as amended, are
available at www.cyberdriveillinois.com.
• Please submit only Form 4.G Report of Sale and the filing fee to the Securities Department. Do not submit the instructions.
• Photocopies of Form 4.G are acceptable if additional copies are needed.
Printed by authority of the State of Illinois. November 2015 — 100 — SEC 330.1
The issuer, controlling person or dealer shall file one copy of the Report of Sale with the Securities Department . A Report of Sale
must be filed within 12 months after the date of the first sale pursuant to Section 4.G of The Illinois Securities Law of 1953.
Each report shall cover a consecutive 12-month period. The filing fee for a Report of Sale is $100.
Illinois Secretary of State
Securities Department
421 E. Capitol Ave., 2nd Floor
Springfield, IL 62701
217-782-2256
Report of Sale
Pursuant to Section 4.G
of The Illinois Securities
Law of 1953
1. Type of Report:
❏ Original Report — No later than 12 months after the first sale of securities made to an Illinois resident in reliance upon Section 4.G of the Act
❏ Amended Report — To correct the Report of Sale dated
2. Issuer Information:
3. Dealer/Controlling Person:
4. Identification of Securities:
❏ Common Stock ❏ Preferred Stock
❏ Notes ❏ Bonds
❏ Debentures ❏ Options
❏ Warrants ❏ Limited Partnership (formed) — FEIN:
❏ Limited Partnership Interests (to be formed) ❏ Fractional undivided interests in an oil, gas or other mineral lease, right or
❏ Other (specify) royalty, including working interests. Complete title and location of the
property:
Date of First Sale to Illinois resident:
Total Dollar Amount sold or to be offered for sale in the reported 12-month period: $
5. Correspondent:
(continued on back)
Printed by authority of the State of Illinois. November 2015 — 100 — SEC 319.1
Name
Telephone Number
Street Address
City, State, ZIP
Name
Telephone Number
Street Address
City, State, ZIP
Firm
Telephone Number
Street Address
City, State, ZIP
Month, Day, Year
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6. Representation by the issuer, controlling person or dealer filing this report in reliance upon Section 4G of
The Illinois Securities Law of 1953
:
If this Report of Sale is not being signed by the issuer, controlling person or dealer, the person who signs this Report is acting as the duly
authorized agent of such issuer, controlling person or dealer. The issuer, controlling person or dealer has duly caused this Report to be
signed on its behalf by the undersigned person. The issuer, controlling person or dealer on whose behalf this Report is being filed
represents, individually or through its duly authorized agent, that:
• The contents of this Report of Sale are true, accurate and complete;
• No commission, discount or other remuneration exceeding 20 percent of the sale price was paid or will be paid, directly or indirectly,
on account of the sale(s) reported herein;
• Sales have not been made or will not be made to more than 35 persons or have involved an aggregate sales price of not more than
$1 million in the reported 12-month period;
• The securities have not been or will not be offered or sold by means of general advertising or general solicitation;
• If a registration statement covering the securities has been filed under the Federal 1933 Act, preliminary prospectuses or
prospectuses contained in such registration statement have not been sent or otherwise delivered to more than 150 Illinois residents;
and
• The securities have not been or will not be sold by any person who is regularly engaged in the business of offering or selling
securities, unless such person is registered under Section 8 of The Illinois Securities Law of 1953 as a dealer or salesperson.
Company, Firm or other Affiliation
Signature
Date of Report
Name (type or print)
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Completed 28 August 2020

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