12 CFR Appendix A to Part 197, Form for Securities Sale Report
Office of the Comptroller of the Currency
If in organization, state the date of FDIC certification of insurance of accounts: ____
State the title, number, aggregate and per-unit offering price of the securities sold: ____
State the aggregate and per-unit dollar amounts of actual itemized offering expenses, discounts, commissions, and other fees: ____
State the aggregate and per-unit dollar amounts of the net proceeds raised: ____
Describe the use of proceeds. If unknown, provide reasonable estimates of the dollar amount allocated to each purpose for which the proceeds will be used: ____
State the number of purchasers of each class of securities sold and the number of owners of record of each class of the issuer's equity securities at the close or termination of the offering: ____
For a non-public offering, also state the factual and legal grounds for the exemption claimed (attach additional pages if necessary): ____
For a non-public offering, all offering materials used should be listed: ____
This issuer has duly caused this securities sale report to be signed on its behalf by the undersigned person.
Instruction: Print the name and title of the signing representative under his or her signature. Ten copies of the securities sale report should be filed, including one copy manually signed, as required under 12 CFR 197.5.