STATE OF CALIFORNIA -- DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF INFORMATION FOR FINDER PURSUANT TO SECTION 25206.1 OF THE CALIFORNIA CORPORATIONS CODE
Instructions: This form is required to:
A natural person, e.g., individual, who does not meet the definition of a finder or the exemption requirements in Corporations Code section 25206.1 is subject to the broker-dealer provisions of Section 25210 of the Corporations Code, if the individual is acting as a broker-dealer as defined in Section 25004 or an agent as defined in Section 25003 of the Corporations Code and is not otherwise exempt from Section 25210 of the Corporations Code.
An individual who meets the exemption requirements as a finder is subject to the prohibition against fraudulent or misleading acts in Corporations Code section 25401.
State the purpose for filing the form by marking the appropriate box below:
[] Initial Statement of Information pursuant to Corporations Code Section 25206.1, subdivision (c), to file for exemption as a finder from the broker-dealer requirements. Complete Sections I and IV, and attach: 1) a check payable to the Department of Business Oversight for the filing fee of $300.00, and 2) a completed Consent to Service of Process (Form 260.165).
[] Renewal Statement of Information pursuant to Corporations Code Section 25206.1, subdivision (d), to renew the exemption as a finder. Complete Sections I, II and IV, and attach a check payable to the Department of Business Oversight for the renewal filing fee of $275.00.
[] Renewal Statement of Information pursuant to Corporations Code Section 25206.1, subdivision (d), to renew the exemption as a finder. Complete Sections I, II and IV, and attach a check payable to the Department of Business Oversight for the renewal filing fee of $275.00.
[] Withdrawal of the exemption pursuant to Section 260.211.6, Title 10, California Code of Regulations. Complete Sections 1 and III. No fee is required.
___________________________
__________________________________________________________ | ||||
(Last Name) | (First Name) | (Middle Name) | (Suffix) |
B. Social Security Number: | DBO File Number: (DBO use only) | |||
(Disclosure of the social security number is voluntary) | ||||
______-______-______ | _________________________ |
[] Business Address: | |||||
___________________________ | |||||
(Number and Street) | (City) | (State) | (Zip) | ||
[] Residential Address: | |||||
___________________________ | |||||
(Number and Street) | (City) | (State) | (Zip) |
_______________________________________________________ | |||||
(Number and Street) | (City) | (State) | (Zip) |
_______________________________________________ | |||||
(Number and Street) | (City) | (State) | (Zip) |
Yes [] | No [] |
Yes [] | No [] |
If you answered "yes" in items H, I, or J, you do not qualify under Section 25206.1 of the Corporations Code for the exemption as a finder from the broker-dealer provisions of Section 25210 of the Corporations Code. You are required to register as a broker-dealer or agent if you are acting as a broker-dealer as defined in Section 25004 or an agent as defined in Section 25003 of the Corporations Code, unless otherwise exempt from Section 25210 of the Corporations Code.
___________________________
By filing this notice with the Commissioner of Business Oversight, Finder hereby represents that (check the appropriate box):
I have not [] I have committed one or more of the described acts or circumstances []
A finder is not eligible to renew the exemption if the finder answered "no " to item numbers 1 or 3, answered item number 2 as having committed one or more of the described acts, or failed to answer item number 4. You are required to register as a broker-dealer or agent pursuant to Section 25210 of the Corporations Code if you are acting as a broker-dealer as defined in Section 25004 or an agent as defined in Section 25003 of the Corporations Code, unless otherwise exempt from Section 25210 of the Corporations Code.
___________________________
[] Check the box if you are withdrawing the exemption as a finder from the broker-dealer requirements. You are required to register as a broker-dealer or an agent pursuant to Section 25210 of the Corporations Code if are acting as a broker-dealer as defined in Section 25004 or an agent as defined in Section 25003 of the Corporations Code, unless otherwise exempt from Section 25210 of the Corporations Code.
Effective Date of Withdrawal: | ___________________________ | ||
Date | |||
___________________________ | |||
Signature of Finder |
___________________________
I, the undersigned, sign this form and certify that the information and statements made in this filing are true and correct. I certify that the books and records will be maintained and preserved, and available for inspection by the Commissioner of Business Oversight as required by Section 25206.1, subdivision (f), of the Corporations Code.
___________________________ | ___________________________ | ||
Date | Filer or Finder Name (Printed) | ||
___________________________ | |||
Signature of Filer or Finder |
The following notices required by state and federal law are provided for those filing for the exemption as a finder from the broker-dealer provisions of the Corporate Securities Law of 1968:
NOTICES REQUIRED UNDER STATE AND FEDERAL LAWIN
FORMATION PRACTICES ACT OF 1977 (California Civil Code Section 1798.17)
FEDERAL PRIVACY ACT OF 1974
Pursuant to Section 7(b) of the Privacy Act of 1974 [5 U.S.C. § 552a note (Disclosure of Social Security Number)], disclosure of a social security number is voluntary. The social security number is solicited pursuant to Section 25206.1 of the California Corporations Code. The social security number is used to 1) verify the individual's identity and eligibility for exemption from the broker-dealer requirements, 2) determine whether the individuals are acting in accordance with the applicable laws, and 3) determine whether the laws administered by the Department of Oversight are being or have been violated and whether administrative action, civil action or referral to appropriate federal, state or local law enforcement or regulatory agencies, as authorized by law, is appropriate.
Cal. Code Regs. Tit. 10, § 260.211.4
Note: Authority cited: Section 25206.1, Corporations Code. Reference: Section 1798.17, Civil Code; Sections 25165, 25206.1 and 25212, Corporations Code; Sections 13140, 13142, 13143 and 13144, Government Code; 17 C.F.R. 230.506(d); and 5 U.S.C. Section 552a note.