Ny Form M 11 – Fill Out and Use This PDF

Issuer Name______________________________________________________________________________________________________

Principal Office Address ____________________________________________________________________________________________

____________________________________________________________________________________________

CityStateZip Code

Telephone Number ________________________________________________________________________________________________

Note: This form should not to be used by issuers engaged in any aspect of real estate or mortgage financing unless they also obtain a letter upon written application pursuant to General Business Law Section 352-e or 352-g. Theatrical Syndication must comply with Article 23 of the Arts and Cultural Affairs Law. Contact the Real Estate Finance Bureau regarding Intrastate offerings pursuant to § 359-ff.

other (specify)_____________________ organized under the laws of ____________________ on _______________________.

2.The business of the issuer is (describe briefly): __________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Total anticipated offering expenses $ _________________ consisting of: Selling: $ ______________________;

Other: $ ______________________.

6.State use of the net proceeds to be obtained: _____________________________________________________________________

_________________________________________________________________________________________________________

IPS M-11 (rev. 9/14)

7.Any secondary offering of securities by selling holders of the issuer, please check box G. Indicate the details of the secondary offering below for each seller.

Name of SellerAddressAnticipated Dollar Amount Offered

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

8. Has registrant, any officer, director or principal or partner ever...

A. been suspended or expelled from membership in any securities or commodities
exchange, association of securities or commodities dealers or investment advisers?	Yes [ ] No [ ]

B.had a license or registration as a dealer, broker, investment adviser or sales person, futures commission merchant, associated person, commodity pool operator, or

commodity trading advisor denied, suspended or revoked?

Yes [ ] No [ ]

C.been enjoined or restrained by any court or government agency from:

	1.	the issuance, sale or offer for sale of securities or commodities?	Yes [	]	No [	]
	2.	rendering securities or commodities advice?	Yes [	]	No [	]
	3.	handling or managing trading accounts?	Yes [	]	No [	]
	4.	continuing any practices in connection with securities or commodities?	Yes [	]	No [	]
D.	been convicted of any crime (other than minor traffic)?		Yes [	]	No [	]
E.	used or been known by any other name?		Yes [	]	No [	]

F.been the subject of any professional disciplinary proceeding, hearing, settled

complaints or arbitrations in excess of $10,000?

Yes [ ] No [ ]

G.been adjudged a bankrupt or made a general assignment for the benefit of creditors; or been

an officer, director or principal of any entity which was reorganized in bankruptcy,
adjudged a bankrupt or made a general assignment for the benefit of creditors?	Yes [ ] No [ ]

H.had an offering of securities within the last the three years or been an officer, director, partner of any entity which had an offering of securities within the

last three years

Yes [ ] No [ ]

I. If the answer to any of the above is "YES", attach a statement of full particulars.

9.Are there any outstanding judgments (not including judgments involving domestic

relations) against the issuer or any officer, director, principal or partner thereof?	Yes [ ] No [ ]
If yes, attach a statement of full particulars.

10.List names or CRD Numbers of all employees (excluding officers and directors) of Issuer who are selling in New York State. A Form U4 must be submitted for each salesperson listed.

Name of EmployeeCRD Number

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

11.Limited Partnerships are required to submit a list of all limited partners as soon as the offering is completed. This may be done in letter form.

12.If the Issuer is a limited partnership list all of the general partners.

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

IPS M-11 (rev. 9/14) Page 2 of 4

13.For each officer, director, principal, partner or managing member, please provide the information requested. In the case of a corporate general partner information must be provided for all officers. Do not refer to a prospectus or offering literature. SEC biographies can be substituted for employment history only. If additional space is necessary, please attach additional pages. Social security numbers and residential information are strictly confidential.

a.	Name: ________________________________________________	Title: ________________________________________
	Address: _____________________________________________________________________________________________
	Prior home addresses for the past 5 years:____________________________________________________________________
	_____________________________________________________________________________________________________
	_____________________________________________________________________________________________________
	Telephone: ____________________________________________	Social Security #: ______________________________
	Date of Birth: __________________________________________	Place of Birth:_________________________________

List employment and business affiliation record for the past five years. (Indicate periods of self-employment and unemployment. Include all corporations or other entities where individual holds or held a substantial equity or controlling interest).

b.	Name: ________________________________________________	Title: _______________________________________
	Address: _____________________________________________________________________________________________
	Prior home addresses for the past 5 years:____________________________________________________________________
	_____________________________________________________________________________________________________
	_____________________________________________________________________________________________________
	Telephone: ____________________________________________	Social Security #: ______________________________
	Date of Birth: __________________________________________	Place of Birth:_________________________________

List complete employment and business affiliation record for the past five years. (Indicate periods of self-employment and unemployment. Include all corporations or other entities where individual holds or held a substantial equity or controlling interest).

IPS M-11 (rev. 9/14) Page 3 of 4

13. Continued

c. Name: ________________________________________________ Title: ________________________________________

Address: _____________________________________________________________________________________________

Prior home addresses for the past 5 years:____________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Telephone: ____________________________________________	Social Security #: ______________________________
Date of Birth: __________________________________________	Place of Birth:_________________________________

List complete employment and business affiliation record for the past five years. (Indicate periods of self-employment and unemployment. Include all corporations or other entities where individual holds or held a substantial equity or controlling interest).

The use of Power of Attorney is not acceptable. If all signatures are not available at time of filing, you must submit the proper total fee and all information required by item 13. One original signature is required at the time of filing. Note in your letter that counterpart forms with missing signatures will be submitted within 30 days of filing.

Limited Partnerships, Limited Liability Corporations and Limited Liability Partnerships must supply one signature for each general partner or managing member. One signature by an officer of a corporate general partner or managing member is sufficient, however, all selling officers must sign.

All officers, directors, partners, controlling principals, or managing members of the registrant listed in Item 13, provide an original signature below. All statements contained herein are true and correct and each individual understands that any false statement shall constitute a violation of Art. 23-A of the General Business Law.

Name and Title (please type or print)	Signature	Date
________________________________________________	______________________________________	____________________
________________________________________________	______________________________________	____________________
________________________________________________	______________________________________	____________________
________________________________________________	______________________________________	____________________
________________________________________________	______________________________________	____________________
________________________________________________	______________________________________	____________________
________________________________________________	______________________________________	____________________

To complete this filing a State Notice and Further State Notice must be filed with the Department of State in Albany. In the case of a non-resident issuer a Consent to Service of Process or U2 must be filed with the Department of State (www.dos.state.ny.us). All changes or amendments to this form must be submitted within 30 days on NY Form M-3 with a $30 fee.

IPS M-11 (rev. 9/14) Page 4 of 4