UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
REPORT OF SALES AND USES OF PROCEEDS PURSUANT TO RULE 257 OF REGULATION A File No. 24- ________ For period ending ____/____/____ Indicate whether the report is an initial report [ ] amendment [ ] or final report [ ]
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If the report is an amendment, indicate the number of such amendment. If the offering has terminated, indicate the date of termination ____/____/____
The report shall be filed in accordance with the provisions of Rule 257 of Regulation A. Answer each item in the box(es) or spaces provided. If additional space is required for any response, continue the response on an attached sheet. If the issuer is required to file any report(s) on this form subsequent to its initial filing, each subsequent filing shall be deemed an amendment to the initial filing. Do not report in any amendment responses to Items 3-11 unless the information has changed. No fee is required to accompany this filing. Seven copies of the form shall be filed with the main office of the Commission in Washington, D.C. At least one copy of the form shall be manually signed; other copies may bear typed or printed signatures. 1.____________________________________________________________________________________________________________________________ Exact name of issuer as specified in its charter. 2. Date of qualification of the offering statement:
3. Has the offering commenced? If yes, date of commencement:
[ ] Yes [ ] No.
If no, explain briefly: ______________________________________________________________________________________________ 4. Did the offering terminate before any securities were sold? [ ] Yes [ ] No. If yes, explain briefly: ___________________________________________________________________________________________ If "yes", do not answer Items 5-11. 5. Did the offering terminate prior to the sale of all the securities qualified under Regulation A? [ ] Yes [ ] No. If yes, explain briefly: __ ________________________________________________________________________________________
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.
SEC 816 (04-05)
6. Indicate the total number of shares or other units offered and sold to date: (issuer's account) Indicate the number of shares or other units still being offered:
(issuer's account) 7. Total amount of dollars received from the public to date. Total amount allocable to selling securityholders: Underwriting discount or commission allowed Underwriting expenses paid Finders' Fees Other expenses paid to date by or for issuer: Legal (including organization) Accounting Engineering Printing and Advertising Other (specify) ____________________________ ____________________________ Total costs and expenses Total net proceeds remaining.
$ $ $ $ $ $ $ $ $ $ $ $
8. Uses of net proceeds to date. Instructions: 1. Do not include any amount in "working capital" to which a more specific category is applicable. 2. Round all amounts to the nearest dollar. 3. Specify under "other purposes" any purpose for which at least 5% of the issuer's proceeds or $50,000, whichever is less, has been used. Salaries and fees Construction of plant, building and facilities Purchases and installation of machinery and equipment Purchase of real estate Acquisition of other business(es) Repayment of indebtedness Working capital Development expense (product development, research, patent costs, etc.) Temporary investment (specify) ____________________________ ____________________________ Other purposes (specify)
____________________________ ____________________________ $ $ $ $ $ $ $ $ $
9. Do the use(s) of proceeds in Item 8 represent a material change in the use(s) of proceeds described in the offering circular? [ ] Yes [ ] No. If yes, explain briefly: __________________________________________________________________________ 10. State the number of shares held by each promoter, director, officer or controlling person of the issuer, if different from the amount stated in the offering circular. 11. List the names and addresses of all brokers and dealers who have, to the knowledge of the issuer or underwriters, participated in the distribution of the securities during the period covered by this report. 2
Pursuant to the requirements of Rule 257 and Regulation A, ______________________________________________________ has caused this report to be signed on its behalf by the undersigned thereunto duly authorized. __________________________________________________________________ Issuer ___________________ Date Instruction: The report shall be signed by an executive officer, general partner or counsel of the issuer or by any other duly authorized person. The name and any title of the person who signs the report shall be typed or printed beneath the signature. By _________________________________________________________________ Signature