Form 440-5001 "Oregon Intrastate Offering Exemption" - Oregon

What Is Form 440-5001?

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 December 1, 2014;
  • 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 440-5001 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 440-5001 "Oregon Intrastate Offering Exemption" - 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://dfcs.oregon.gov
OREGON INTRASTATE OFFERING EXEMPTION
Pursuant to ORS 59.035(15); OAR 441-035-0110
This form may be used by an issuer seeking to notify the director under OAR 441-035-0110 of its intent to advertise,
offer, and sell securities in reliance on OAR 441-035-0070 to 441-035-0230 (the “Oregon Intrastate Offering
Exemption”). All fields must be completed.
New
Amended
1. Name of issuer:
Address of principal executive office of issuer:
City:
State:
ZIP:
URL:
2. Name of contact person to receive notices and communications regarding the offering:
Contact person’s phone number:
Contact person’s email address:
Contact person’s mailing address:
City:
State:
ZIP:
3. Maximum offering amount: $
4. Minimum offering amount, if applicable: $
5. Provide the name of third-party platform provider (if any) that the issuer intends to use to advertise, offer, or sell its
securities:
Make check or money order payable to Oregon
Mail application with payment to:
Department of Consumer & Business Services. If paying
DCBS Fiscal Services
by credit card, applicant must sign credit card information
P.O. Box 14610
box. Do not fax; do not send cash.
Salem, OR 97309-0445
Visa
MasterCard
Discover
Phone:
(
)
Fiscal use only: 62110/1008
/
Credit card number
Expiration
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
Page 1
440-5001 (12/14/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://dfcs.oregon.gov
OREGON INTRASTATE OFFERING EXEMPTION
Pursuant to ORS 59.035(15); OAR 441-035-0110
This form may be used by an issuer seeking to notify the director under OAR 441-035-0110 of its intent to advertise,
offer, and sell securities in reliance on OAR 441-035-0070 to 441-035-0230 (the “Oregon Intrastate Offering
Exemption”). All fields must be completed.
New
Amended
1. Name of issuer:
Address of principal executive office of issuer:
City:
State:
ZIP:
URL:
2. Name of contact person to receive notices and communications regarding the offering:
Contact person’s phone number:
Contact person’s email address:
Contact person’s mailing address:
City:
State:
ZIP:
3. Maximum offering amount: $
4. Minimum offering amount, if applicable: $
5. Provide the name of third-party platform provider (if any) that the issuer intends to use to advertise, offer, or sell its
securities:
Make check or money order payable to Oregon
Mail application with payment to:
Department of Consumer & Business Services. If paying
DCBS Fiscal Services
by credit card, applicant must sign credit card information
P.O. Box 14610
box. Do not fax; do not send cash.
Salem, OR 97309-0445
Visa
MasterCard
Discover
Phone:
(
)
Fiscal use only: 62110/1008
/
Credit card number
Expiration
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
Page 1
440-5001 (12/14/COM)
6. Names and addresses of the issuer’s current officers, directors, principals, managing partners, and shareholders
possessing an interest of 20 percent or more in the issuer, or anyone holding a substantially similar portion:
7. Briefly describe the issuer’s business or proposed business (attach additional sheets, if necessary):
8. Briefly describe the issuer’s proposed product or project that is the reason for the offering (attach additional sheets,
if necessary):
9. Briefly describe the purpose of the proposed offering (attach additional sheets, if necessary):
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440-5001 (12/14/COM)
ADDITIONAL QUESTIONS
Answer each of the following questions to the best of your ability. (Attach a statement of explanation, if necessary.)
YES
NO
Is the issuer a business formed under Oregon laws and registered with Oregon’s Secretary of State?
Is the issuer’s principal office located in Oregon?
Does the issuer have 50 or fewer employees?
Has the issuer met with a business technical service provider?
Name of the technical service provider:
Date(s) of the meeting:
Within the past five years, has the issuer or person affiliated with the issuer:
Filed a registration statement that is the subject of any pending proceeding or examination under
section 8 of the Securities Act of 1933 or has been the subject of any refusal order or stop order
thereunder?
Been subject to any pending proceeding under SEC rule 258 promulgated under the Securities Act
of 1933, or any similar section adopted under section 3(b) of the Securities Act of 1933, or to an
order entered thereunder?
Been convicted of any felony or misdemeanor involving the offer, purchase or sale of any
security, or any felony or misdemeanor involving dishonesty or involving the making of any false
filing related to the offer or sale of any security?
Been subject to a state administrative order or judgment containing findings that the issuer or person
affiliated with the issuer engaged in fraud or deceit, including but not limited to, making untrue
statements of material fact and/or omitting to state material facts, in connection with this purchase or
sale of securities?
Been subject to any order, judgment, or decree of any court of competent jurisdiction or regulatory
authority (including non-U.S. regulatory authorities) preliminarily, temporarily, or permanently
restraining or enjoining such person from engaging in or continuing any conduct or practice in
connection with the purchase or sale of any security or involving the making of any false filing
related to the offer orsale of any security?
Been the subject of a cease and desist order entered after notice and opportunity of a hearing by the
director, a securities agency, or administrator of another state or Canadian province or territory, the
United States Securities and Exchange Commission, or the United States Commodities Futures
Trading Commission that contains allegations of securities fraud or misrepresentations in connection
with investment offerings?
CERTIFICATION
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440-5001 (12/14/COM)
I certify that I have made reasonable efforts to verify the accuracy and completeness of the information
contained in this form and the attached documents. I also affirm that I am aware of and will comply with all
applicable requirements under the Oregon Intrastate Offering Exemption, including the requirement that this
form be amended if there are any material changes to the form.
I am duly authorized by the issuer to sign this certification.
Signature:
Printed Name and Title:
Date:
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440-5001 (12/14/COM)
ADDITIONAL INFORMATION
To properly file this form, the issuer must send this form and applicable fee to one of the following addresses:
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 Street, NE, Room 410
Salem, OR 97301-3881
The $200 filing fee may be paid by providing credit card information in the designated section of this form or by
check. Checks must be made payable to “Director, Department of Consumer and Business Services.”
This form must be filed not less than seven days before the issuer advertises, offers, or sells securities in reliance
in the Oregon Intrastate Offering Exemption.
The issuer must include copies of its offering and proposed advertising materials with this form.
The division will notify the correspondent identified on this form that it has received the filing after it has received
a completed filing.
The issuer must amend this filing if there are any material changes to the filing.
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440-5001 (12/14/COM)
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