Form SFN51969 (NP) "Nonprofit Organization Claim of Exemption" - North Dakota

What Is Form SFN51969 (NP)?

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

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the North Dakota Securities Department;
  • 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 SFN51969 (NP) by clicking the link below or browse more documents and templates provided by the North Dakota Securities Department.

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Download Form SFN51969 (NP) "Nonprofit Organization Claim of Exemption" - North Dakota

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Securities Department
NONPROFIT ORGANIZATION CLAIM OF
600 East Boulevard
EXEMPTION - FORM NP
Bismarck, ND 58505
NORTH DAKOTA SECURITIES DEPARTMENT
(701) 328-2910
SFN 51969 (10-2013)
www.nd.gov/securities
Securities Commissioner to the State of North Dakota:
Under oath and pursuant to the provisions of N.D.C.C. Section 10-04-05(5) the undersigned applies for an exemption from the registration
requirements of the Securities Act of 1951 and submits the following SWORN answers to the questions contained herein for the purpose
of applying to the Securities Commissioner for approval of the requested exemption.
INITIAL
RENEWAL
(If insufficient space is available for answers, please attach a separate sheet)
1. Name of Issuer
Telephone Number
2. Address of Issuer
City
State
ZIP Code
3. Name of correspondent to whom notices and communications regarding this claim of exemption should be sent
Address
Telephone Number
City
State
ZIP Code
4. Specify legal form of issuer (corporation, partnership, association, or other entity):
5. State of Incorporation or Organization:
Date of Incorporation or Organization:
6. State whether the issuer is organized and operated for religious, educational, benevolent, fraternal, charitable, social, or reformatory
purposes:
7. Include proof of current tax status under the Internal Revenue Code:
Yes
Incorporated by reference for renewal:
8. Describe briefly the general character of the issuer's business:
Securities Department
NONPROFIT ORGANIZATION CLAIM OF
600 East Boulevard
EXEMPTION - FORM NP
Bismarck, ND 58505
NORTH DAKOTA SECURITIES DEPARTMENT
(701) 328-2910
SFN 51969 (10-2013)
www.nd.gov/securities
Securities Commissioner to the State of North Dakota:
Under oath and pursuant to the provisions of N.D.C.C. Section 10-04-05(5) the undersigned applies for an exemption from the registration
requirements of the Securities Act of 1951 and submits the following SWORN answers to the questions contained herein for the purpose
of applying to the Securities Commissioner for approval of the requested exemption.
INITIAL
RENEWAL
(If insufficient space is available for answers, please attach a separate sheet)
1. Name of Issuer
Telephone Number
2. Address of Issuer
City
State
ZIP Code
3. Name of correspondent to whom notices and communications regarding this claim of exemption should be sent
Address
Telephone Number
City
State
ZIP Code
4. Specify legal form of issuer (corporation, partnership, association, or other entity):
5. State of Incorporation or Organization:
Date of Incorporation or Organization:
6. State whether the issuer is organized and operated for religious, educational, benevolent, fraternal, charitable, social, or reformatory
purposes:
7. Include proof of current tax status under the Internal Revenue Code:
Yes
Incorporated by reference for renewal:
8. Describe briefly the general character of the issuer's business:
SFN 51969 (10-2013)
Page 2 of 3
9. List the states in which it is proposed to offer the securities for sale:
10. List the states, if any, in which the securities are eligible for sale:
11. List the states, if any, which have refused, by order or otherwise, to authorize the sale of the securities or have suspended or revoked
the right to sell the securities, or in which an application has been withdrawn:
12. Title or class of each security to be offered for sale pursuant to this claim of exemption
13. Price per Security
14. Minimum dollar amount of securities which will be offered to any one offeree
15. Furnish the name of any entity and person who will act on behalf of the issuer in effecting the offers and sales of securities in North Dakota
16. State the compensation to be paid directly or indirectly to each entity or person identified in Item 15 above
17. Provide a short description of the proposed use of the proceeds from the sale of the securities:
18. The issuer and the entities and persons acting on behalf of the issuer in effecting the offers and sales of securities in North Dakota
understand a copy of the offering disclosure document must be provided to each person to whom an offer to sell or sale is made.
Yes
SFN 51969 (10-2013)
Page 3 of 3
19. The issuer and the entities and persons acting on behalf of the issuer in effecting the offers and sales of securities in North Dakota
understand that receipt and approval of the claim of exemption by the North Dakota Securities Department does not signify that the
Commissioner has passed upon the merits or qualifications of, or recommended these securities. Any representation to the contrary
is a criminal offense.
Yes
20. Attach a copy of the offering disclosure document proposed to be used in connection with the offer to sell the securities which are the
subject of this claim of exemption, including financial statements for each of the last two fiscal years of the issuer.
21. If the issuer is incorporated in or organized under a jurisdiction other than North Dakota, furnish a Consent to Service of Service
(FORM U-2).
Incorporated by reference for renewal:
Yes
22. The filing fee of $150.00 must accompany this claim of exemption for an initial filing.
The filing fee of $100.00 must accompany this claim of exemption for renewal of a filing.
Pursuant to the requirements of N.D.C.C. Section 10-04-05(5), the issuer has duly caused this Nonprofit Organization Claim of Exemption to
be signed on its behalf by the undersigned.
Yes
Date
Type or Printed Name of Signatory
Signature
Title
Subscribed and sworn to before me this
day
,
.
(Notary Public Signature)
In and for the County of
State of
My commission expires on:
Page of 3