Form DBO-260.151(B) "Statement of Transferee to Accompany Application for Consent to Transfer Securities Subject to Legend or Escrow Condition" - California

What Is Form DBO-260.151(B)?

This is a legal form that was released by the California Department of Business Oversight - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the California Department of Business Oversight;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DBO-260.151(B) by clicking the link below or browse more documents and templates provided by the California Department of Business Oversight.

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Download Form DBO-260.151(B) "Statement of Transferee to Accompany Application for Consent to Transfer Securities Subject to Legend or Escrow Condition" - California

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STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF TRANSFEREE TO ACCOMPANY APPLICATION
FOR CONSENT TO TRANSFER SECURITIES SUBJECT TO LEGEND OR
ESCROW CONDITION
DBO–260.151(b) (Register 2002, No. 39) (Rev. 10-17)
TO THE COMMISSIONER OF BUSINESS OVERSIGHT OF
THE STATE OF CALIFORNIA:
(If securities are to be received in pledge, so state.)
The undersigned intends to purchase* _________________________ shares or units of
(number)
________________________________________________________________________________
(Description of security, e.g., $10 common, Class A common)
issued by ________________________________________________________________________
(Name of Issuer)
from ________________________________________ and makes the following statements:
1.
I have received from the issuer and/or the transferor a recent financial statement of the issuer
and such additional information with respect to the issuer as I have deemed necessary to
make an independent evaluation of the business prospects of the issuer and the fairness of the
investment:
(If answered in the negative, explain fully.)
Yes
No
2.
I am a director and/or an office of issuer ………………………………
Yes
No
3.
(a) I will actively participate in the operation of issuer’s business and devote my full time or a
substantial portion of my time thereto, with an opportunity to be fully aware of all of issuer’s
affairs………………………………………………………………………
Yes
No
(b) I will be compensated for such services……………………………
Yes
No
4.
Are the securities being purchased promotional shares subject to waivers of assets and
dividend? (See Sections 260.141 and 260.141.1 of the rules)
Yes
No
5.
If the issuer is not a partnership and all parts of questions 2 and 3 above are answered in the
negative, attach a separate signed statement elaborating on the items shown below:
(a) The length of time officers and directors of issuer have been known, and the nature of prior
business dealings with any officer or director of issuer or with the issuer.
(b) Any prior investment experience in a business of similar size and nature.
(c) Whether the amount of the proposed investment in issuer is in excess of 10% of either the
net worth or the annual income of the transferee.
(d) Whether the transferee has received advice from any attorney, accountant or other
professional adviser independent of the issuer.
(e) How transferee became aware of proposed investment.
6.
If the issuer is a partnership, complete the following:
(a) My annual income is in excess of $____________________________.
(b) My net worth (exclusive of my home, its furnishings and my automobiles) is in excess of
$________________________.
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF TRANSFEREE TO ACCOMPANY APPLICATION
FOR CONSENT TO TRANSFER SECURITIES SUBJECT TO LEGEND OR
ESCROW CONDITION
DBO–260.151(b) (Register 2002, No. 39) (Rev. 10-17)
TO THE COMMISSIONER OF BUSINESS OVERSIGHT OF
THE STATE OF CALIFORNIA:
(If securities are to be received in pledge, so state.)
The undersigned intends to purchase* _________________________ shares or units of
(number)
________________________________________________________________________________
(Description of security, e.g., $10 common, Class A common)
issued by ________________________________________________________________________
(Name of Issuer)
from ________________________________________ and makes the following statements:
1.
I have received from the issuer and/or the transferor a recent financial statement of the issuer
and such additional information with respect to the issuer as I have deemed necessary to
make an independent evaluation of the business prospects of the issuer and the fairness of the
investment:
(If answered in the negative, explain fully.)
Yes
No
2.
I am a director and/or an office of issuer ………………………………
Yes
No
3.
(a) I will actively participate in the operation of issuer’s business and devote my full time or a
substantial portion of my time thereto, with an opportunity to be fully aware of all of issuer’s
affairs………………………………………………………………………
Yes
No
(b) I will be compensated for such services……………………………
Yes
No
4.
Are the securities being purchased promotional shares subject to waivers of assets and
dividend? (See Sections 260.141 and 260.141.1 of the rules)
Yes
No
5.
If the issuer is not a partnership and all parts of questions 2 and 3 above are answered in the
negative, attach a separate signed statement elaborating on the items shown below:
(a) The length of time officers and directors of issuer have been known, and the nature of prior
business dealings with any officer or director of issuer or with the issuer.
(b) Any prior investment experience in a business of similar size and nature.
(c) Whether the amount of the proposed investment in issuer is in excess of 10% of either the
net worth or the annual income of the transferee.
(d) Whether the transferee has received advice from any attorney, accountant or other
professional adviser independent of the issuer.
(e) How transferee became aware of proposed investment.
6.
If the issuer is a partnership, complete the following:
(a) My annual income is in excess of $____________________________.
(b) My net worth (exclusive of my home, its furnishings and my automobiles) is in excess of
$________________________.
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF TRANSFEREE TO ACCOMPANY APPLICATION
FOR CONSENT TO TRANSFER SECURITIES SUBJECT TO LEGEND OR
ESCROW CONDITION
DBO–260.151(b) (Register 2002, No. 39) (Rev. 10-17) Page 2 of 2
7.
(a) I am acquiring the securities as record and beneficial owner.
Yes
No
(b) I am acquiring the securities as beneficial owner and not as record owner.
Yes
No
The record owner is ____________________________________________.
(c) I am acquiring the securities as record owner and have no beneficial interest therein.
……………………………………………………………………………………
Yes
No
The beneficial owner is _________________________________________.
*Include rights, warrants, and options and the securities to be transferred upon exercise thereof.
If the transferee is other than an individual, the name of the entity should be typed or printed
beside the signature line exactly as shown in Item 4 of the Transferor’s Application (Form 260.151).
The signature should show the name and title of the person authorized to sign for the transferee.
I certify (or declare) under penalty of perjury under the laws of the State of California that I
have read this Statement of Transferee and know the contents thereof, and that the statements
therein are true and correct.
Executed at _______________________________________, ___________________, 20 _______.
(Place)
(Date)
________________________________________
___________________________________
(Name of Entity)
(Signature of Transferee)
___________________________________
(Title)
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