Form 440-5180 "Certain Compensatory Benefit Plans" - Oregon

What Is Form 440-5180?

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

Form Details:

  • Released on February 1, 2017;
  • The latest edition provided by the Oregon Department of Consumer and Business Services;
  • 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 printable version of Form 440-5180 by clicking the link below or browse more documents and templates provided by the Oregon Department of Consumer and Business Services.

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Download Form 440-5180 "Certain Compensatory Benefit Plans" - Oregon

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Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Room 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14610, Salem, OR 97309-0445
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
CERTAIN COMPENSATORY BENEFIT PLANS
Under ORS 59.035(15); OAR 441-035-0300
This form may be used by an issuer seeking to notify the director under OAR 441-035-0300 of its intent to offer
benefit plan
and sell securities under a written compensatory
that is exempt under SEC Rule 701.
All fields must be completed.
New
Amended
Filing date (if later than the date the division receives the filing):
1.
Name of issuer:
2.
Address of principal executive office of issuer:
City:
State:
ZIP:
Type of business organization:
3.
Name of correspondent
4.
:
’s phone number
Correspondent
:
’s email address:
Correspondent
’s mailing address:
Correspondent
City:
State:
ZIP:
Maximum offering amount: $
5.
Full title of the plan:
6.
Will the offer and sale of securities under the plan be exempt under SEC Rule 701?:
7.
Secure fax for credit card payments:
Make check or money order payable to Oregon
Department of Consumer and Business Services.
503-947-2333
If paying by credit card, applicant must sign
Mail notice with payment to:
DCBS — Fiscal Services
credit-card information box.
P.O. Box 14610
Salem, OR 97309-0445
Visa
MasterCard
Discover
Phone:
Fiscal use only: 62110/1002
Credit card number
Expiration date
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
1
440-5180 (2/17/COM)
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Room 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14610, Salem, OR 97309-0445
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
CERTAIN COMPENSATORY BENEFIT PLANS
Under ORS 59.035(15); OAR 441-035-0300
This form may be used by an issuer seeking to notify the director under OAR 441-035-0300 of its intent to offer
benefit plan
and sell securities under a written compensatory
that is exempt under SEC Rule 701.
All fields must be completed.
New
Amended
Filing date (if later than the date the division receives the filing):
1.
Name of issuer:
2.
Address of principal executive office of issuer:
City:
State:
ZIP:
Type of business organization:
3.
Name of correspondent
4.
:
’s phone number
Correspondent
:
’s email address:
Correspondent
’s mailing address:
Correspondent
City:
State:
ZIP:
Maximum offering amount: $
5.
Full title of the plan:
6.
Will the offer and sale of securities under the plan be exempt under SEC Rule 701?:
7.
Secure fax for credit card payments:
Make check or money order payable to Oregon
Department of Consumer and Business Services.
503-947-2333
If paying by credit card, applicant must sign
Mail notice with payment to:
DCBS — Fiscal Services
credit-card information box.
P.O. Box 14610
Salem, OR 97309-0445
Visa
MasterCard
Discover
Phone:
Fiscal use only: 62110/1002
Credit card number
Expiration date
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
1
440-5180 (2/17/COM)
CERTIFICATION
I certify that I have made reasonable efforts to verify the accuracy and completeness of the
information contained in this notice and the attached documents. I also affirm that the issuer is
aware of and will comply with all applicable requirements under Oregon Administrative Rule
441-035-3000, including that offers and sales under the Plan will be exempt under SEC Rule 701
and that this notice will be amended if there are any material changes to the form or the Plan.
I am duly authorized by the issuer to sign this certification.
Signature:
Printed name and title:
Date:
2
440-5180 (2/17/COM)
MORE INFORMATION
To properly file this notice, the issuer must send this
notice and the applicable non-refundable filing fee to one of the following address:
Fiscal Services Section
Department of Consumer and Business Services
P.O. Box 14610
Salem, OR 97309-0445
OR
Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St., NE, Room 410
Salem, OR 97301-3881
The filing fee can be paid by providing credit card
information in the designated section of this notice or by check. Checks must be made
payable to “Oregon Department of Consumer and Business Services.”
The division will consider this notice to be filed
when the notice is received by the division, or the date specified by the issuer in No. 1,
whichever is later.
Once filed, the division will send a Notice of Filing
to the correspondent identified on this form.
The issuer must amend this notice when there are
any material changes to this notice, including a change in the name of the offering, or an
increase in the aggregate offering amount identified in No. 5 of this notice. The issuer
must pay another non-refundable filing fee for any amended notice that increases the
aggregate offering amount.
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440-5180 (2/17/COM)
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