563g.20—Form for securities sale report.
Office of Thrift Supervision, 1700 G Street, NW., Washington, DC 20552
[Form G-12]
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 12 CFR 563g.5.
Attention
Intentional misstatements or omissions of fact constitute violations of Federal law (See 18 U.S.C. 1001 and 12 CFR 563.180(b)).