Fillable Printable Form 1-Z
Fillable Printable Form 1-Z
Form 1-Z
__________________________________________________________________________________
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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 1-Z
EXIT REPORT UNDER REGULATION A
GENERAL INSTRUCTIONS
(1) The following information must be provided in the XML-based Form 1-Z available through the EDGAR
portal. The format shown below may differ from the electronic version available on EDGAR.
(2) An issuer filing this Form pursuant to Rule 257(a) must only complete the Preliminary Information and Part
I.
(3) An issuer filing this Form to suspend its duty to file reports under Rule 257(d) must complete the Prelimi-
nary Information and Part II. Such issuer must also provide Part I if it has not previously provided the Part I
information in a Form 1-K filing.
* * * * * *
PRELIMINARY INFORMATION
Exact name of issuer as specified in the issuer’s charter: _____________________________________
Address of Principal Executive Offi ces: __________________________________________________
Phone: ( ) ____________________________
Commission File Number(s): _________________________________________________________
PART I
Summary Information Regarding the Offering and Proceeds
Date of qualification of the offering statement:______________________________
Date of commencement of the offering: ___________________________________
Amount of securities qualified to be sold in the offering:______________________
Amount of securities sold in the offering:__________________________________
Price per security: $____________________________________
The portion of aggregate sales attributable to securities sold on behalf of the issuer:
$______________________
Persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB control number.
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The portion of aggregate sales attributable to securities sold on behalf of selling securityholders:
$_______________________________
Fees in connection with this offering and names of service providers:
Name of Service Provider Fees
Underwriters: _____________________ $__________________
Sales Commissions: _____________________ $__________________
Finders’ Fees: _____________________ $__________________
Audit: _____________________ $__________________
Legal: _____________________ $__________________
Promoters: _____________________ $__________________
Blue Sky Compliance: _____________________ $__________________
CRD Number of any broker or dealer listed: _______________________________
Net proceeds to the issuer: $ ____________________________________________
Clarification of responses (if necessary): __________________________________
PART II
Certification of Suspension of Duty to File Reports
Title of each class of securities covered by this Form _________________________
Commission File Number(s)_____________________________________________
Approximate number of holders of record as of the certification date: ____________
Pursuant to the requirements of Regulation A, _________________________ (Name of issuer as specifi ed in
charter) certifies that it meets all of the conditions for termination of Regulation A reporting specified in Rule
257(d) and that there are no classes of securities other than those that are the subject of this Form 1-Z regarding
which the issuer has Regulation A reporting obligations. ______________________ (Name of issuer as speci-
fied in charter) has caused this certification to be signed on its behalf by the undersigned duly authorized person.
By: __________________________ Date: ______________________________
Title: _________________________
Instruction: This Part II of Form 1-Z is required by Rule 257(d) of Regulation A. An officer of the issuer or any
other duly authorized person may sign, and must do so by typed signature. The name and title of the person
signing the form must be typed or printed under the signature. The signatory to the filing must also manually
sign a signature page or other document authenticating, acknowledging or otherwise adopting his or her signa-
ture that appears in the filing. Such document must be executed before or at the time the filing is made and must
be retained by the issuer for a period of five years. Upon request, the issuer must furnish to the Commission or
its staff a copy of any or all documents retained pursuant to this instruction.
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