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TITLE 12 - BANKS AND BANKING
CHAPTER V - OFFICE OF THRIFT SUPERVISION, DEPARTMENT OF THE TREASURY
PART 563G - SECURITIES OFFERINGS
563g.20 - Form for securities sale report.
Office of Thrift Supervision, 1700 G Street, NW., Washington, DC 20552 [Form G12] Securities Sale Report Pursuant to 563g.12 OTS No. ____________________ Issuer's Name: ____________________ Address:____________________ 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: ______ Person to Contact: ____________________ Telephone No.:____________________ This issuer has duly caused this securities sale report to be signed on its behalf by the undersigned person. Date of securities sale report ____________________ Issuer: ____________________ Signature: ____________________ Name: ____________________ Title:____________________ 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
Attention Intentional misstatements or omissions of fact constitute violations of Federal law (See 18 U.S.C. 1001 and
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