Ohio Form 3 Q – Fill Out and Use This PDF

											File Number
									77 South High Street, 22nd Floor
									Columbus, Ohio 43215-6131		Telephone
										Form 3-Q	(614) 644-7381
									REPORT OF SALE OF
									SECURITIES
										1707.03(Q)
Claimant Must Not fill									Checked
	In.							Date	By		Notation
Division Record --
Fee ($100/$50 Received
Prior filings
checked
Examined as to form
Amendment Requested
Accepted for
Filing
Record
Made
Examination
Requested
Exemption 3-Q (Claimant Must Not Fill In.
(File)		(Date)						(Amount)		(Description)	(Price)

Note: Use this form to claim a section 1707.03(Q) exemption for securities sold in Ohio within 60 days of the filing of this form and not previously reported. Only those issuers relying on Section 4(2) of the Securities Act of 1933 are eligible to use this exemption. The non-refundable filing fee is $100 for the first filing and $50 for any subsequent related Form 3-Q filing made during the same calendar year.

Submit to the Ohio Division of Securities, 77 South High Street, Columbus, Ohio 43215-6131 the following: (1) the completed Form 3-Q, (2) the filing fee by check or money order payable to the “Ohio Division of Securities”, and (3) exhibits or schedules, if any.

1.Issuer's full name

Payer’s Federal Tax Identification Number

2.Issuer's Address

(City, State, Zip)

(Phone No.)

3.	State	of	Type of
	incorporation/formation		entity

(Corporation, Partnership, etc.)

4.Correspondence regarding this report should be sent to:

(Name)

(Street)

(City, State, Zip Code)

(Phone No.)

5.A section 1707.03(Q) claim of exemption is being made for the following securities sold in Ohio within 60 days of the filing of this form and not previously reported (use additional sheet, if necessary):

Type of		Date of		Number of		Price		Number of
Securities Sold		Sale		Units Sold		per Unit		Purchasers

Note: O.A.C. rule 1301:6-3-03(B)(5) deems a sale to have occurred on the later of: (a) the date that a subscription agreement or its equivalent, signed by the purchaser, is received by the issuer or the dealer, or the purchaser transfers or loses control of the purchase funds, whichever is earlier; or (b) the first date of disbursement of any proceeds of the sale of the securities which have been deposited directly into an escrow account.

6.Confirm that the basis in law for this claim of exemption from Section 5 of the Securities Act of 1933 is pursuant to Section 4(2) of that Act. Note that Rules 504, 505 and 506 cannot be used as a basis for claiming the exemption pursuant to Section 1707.03(Q).

7.List the total number of persons who have purchased this offering to date, both in and outside of Ohio, including persons claimed on all previous Form 3-Qs filed in connection with this offering.

8.(a) List any commissions, discounts, or other remuneration paid or to be paid or given to any person, directly or indirectly, for sales in Ohio of the securities claimed on the Form 3-Q (if none, please state “None”). Use additional sheet if necessary.

Name and address of person		Amount of		Percentage of
receiving commission, etc.		commission, etc.		the Initial Offering Price

(b)Were above commissions, discounts, or other remuneration paid or given only to dealers or salesmen licensed

under Chapter 1707 of the Revised Code?

 YES

 NO

9.Was an offering circular used in connection with the sales reported on this Form 3-Q?

 YES	 NO
If yes,	 Copy attached or  Previously submitted
10. Has this offering been terminated?			 YES	 NO
If yes, date of termination

11.Incorporated issuers not domiciled in this state or unincorporated issuers having a situs of its principal place of business outside this state must file a Form 11 or Form U-2. (See section 1707.11, R.C.)

SIGNATURE

The undersigned represents that the foregoing information is true as of the date hereof and agrees that this report shall be considered a written statement used for the purpose of selling securities in Ohio within the meaning of Section 1707.44(B) of the Ohio Revised Code. The individual signing this report on behalf of the issuer further represents that he/she is duly authorized by the issuer to execute and file this report.

Issuer or

Dealer

		(Full Name)
B
y
	(Signature)	(Date)
	(Name)	(Official Capacity)

The Division suggests Form 3-Q be sent certified mail for verification of receipt, or send a copy of this form together with a self-addressed, stamped envelope.

Com 4596 (Rev. 2/05)

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