Private Placement Advisors LLC 





advising on exempt offerings to find investors.  

Model Accredited Exemption


SEC MODEL ACCREDITED INVESTOR EXEMPTION



UNIFORM NOTICE OF TRANSACTION


NOTICE OF SALE OF SECURITIES PURSUANT TO ACCREDITED INVESTOR

EXEMPTION


______________________________________________________________________________

1. Issuer

Name: ____________________________________________________

Address: ____________________________________________________

Phone Number: ____________________________________________________

______________________________________________________________________________

2. Form of Organization (Check One)

( ) Corporation ( ) Unincorporated Association ( ) Limited Liability Company

( ) Limited Partnership ( ) Other (Specify) __________________________

Issuer's state of Incorporation or jurisdiction or organization _______________________

Date of Incorporation or Organization _________________________________________

______________________________________________________________________________

  1. Officers and Directors (or persons acting in a similar capacity)

Names, Addresses, and Phone Numbers:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

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5. Description of business:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

______________________________________________________________________________

  1. Name of Broker-Dealer who has solicited or intends to solicit purchasers in this state.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

Business Address

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

By filing this Notice of Transaction, the issuer of these securities hereby represents that:

  • Sales of securities shall be made only to accredited investors as defined in 17 CFR 230.501(a).
  • The issuer is not an issuer in the development stage that either has no specific business plan or purpose or has indicated that its business plan is to engage in a merger or acquisition with an unidentified company or companies, or other entity or person.
  • The issuer reasonably believes that all purchasers are purchasing for investment and not with the view to or for sale in connection with a distribution of the security. Any resale of a security sold in reliance on this exemption within 12 months of sale, except a resale to an accredited investor or pursuant to a registration statement effective under applicable state securities law, shall be presumed to be with a view to distribution and not for investment. Securities issued under this exemption may only be resold pursuant to registration or an exemption under applicable state securities law.

The undersigned represents that the issuer is familiar with the conditions that must be satisfied to be entitled to the Accredited Investor Exemption of the state in which this notice is filed and understands that the issuer claiming the availability of this exemption has the burden of establishing that these conditions have been satisfied.

The issuer has read this notification and knows the contents to be true and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person.

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