The Ohio 3-Q form is a document used to claim an exemption for securities sold in Ohio under section 1707.03(Q). This form must be filed within 60 days of the securities sale and is applicable to issuers relying on Section 4(2) of the Securities Act of 1933. Proper submission includes a completed form, a filing fee, and any necessary exhibits.
The Ohio 3 Q form is a crucial document for issuers looking to claim an exemption under Section 1707.03(Q) of the Ohio Revised Code. This form allows for the reporting of securities sold in Ohio within 60 days, provided they have not been previously reported. It's essential for issuers relying on Section 4(2) of the Securities Act of 1933, as only they are eligible to utilize this exemption. A non-refundable filing fee of $100 applies to the first filing, while subsequent related filings within the same calendar year incur a fee of $50. To properly submit the form, issuers must send the completed document along with the appropriate fee and any necessary exhibits to the Ohio Division of Securities. The form requires detailed information about the issuer, the securities sold, and any commissions or remuneration related to the sales. Additionally, it asks for confirmation that the basis for the exemption is indeed Section 4(2) and not any other rules. Given the specific requirements and the importance of compliance, completing the Ohio 3 Q form accurately and submitting it promptly is vital for any issuer engaged in securities sales within the state.
File Number
Form 3-Q
Report of Sale of Securities
1707.03(Q)
Claimant Must Not fill In.
Checked
DIVISION RECORD ONLY
Date
By
Notation
Fee ($100/$50) Received
Prior filings checked
Examined as to form
Amendment Requested
Accepted for Filing
Record Made
Examination Requested
Exemption 3-Q (Claimant Must Not Fill In).
(File)
(Date)
(Amount)
(Description)
(Price)
Note: Use this form to claim a section 1707.03(Q) exemption for securities sold in Ohio within 60 days of the filing of this form and not previously reported. Only those issuers relying on Section 4(2) of the Securities Act of 1933 are eligible to use this exemption. The non-refundable filing fee is $100 for the first filing and $50 for any subsequent related Form 3-Q filing made during the same calendar year.
Submit to the Ohio Division of Securities, 77 South High Street, 22nd Floor, Columbus, Ohio 43215-6131 the following: (1) the completed Form 3-Q, (2) the filing fee by check or money order payable to the “Ohio Division of Securities”, and (3) exhibits or schedules, if any.
1.Issuer's full name
(Payer’s Federal Tax Identification Number)
2.Issuer's Address
(City, State, Zip)(Phone No.)
3. State of incorporation/formation
Type of entity
(Corporation, Partnership, etc.)
Division of Securities
614-644-7381
77 South High Street
Fax: 614-728-2846
22nd Floor
Investor Protection Hotline:
Columbus, Ohio 43215
877-683-7841
COM 4596
TTY/TDD: 800-750-0750
4/11/19
An Equal Opportunity Employer and Service Provider
com.ohio.gov
Ohio Department of Commerce
FORM 3-Q
4.Correspondence regarding this report should be sent to:
(Name)
(Street)
(City, State, Zip Code)
(Phone No.)
5.A section 1707.03(Q) claim of exemption is being made for the following securities sold in Ohio within 60 days of the filing of this form and not previously reported (use additional sheet, if necessary):
Type of
Date of
Number of
Price
Securities Sold
Sale
Units Sold
per Unit
Purchasers
Note:
O.A.C. rule 1301:6-3-03(B)(5) deems a sale to have occurred on the later of: (a) the date that a subscription
agreement or its equivalent, signed by the purchaser, is received by the issuer or the dealer, or the purchaser
transfers or loses control of the purchase funds, whichever is earlier; or (b) the first date of disbursement of
any proceeds of the sale of the securities which have been deposited directly into an escrow account.
6.Confirm that the basis in law for this claim of exemption from Section 5 of the Securities Act of 1933 is pursuant to Section 4(2) of that Act. Note that Rules 504, 505 and 506 cannot be used as a basis for claiming the exemption pursuant to Section 1707.03(Q).
7.List the total number of persons who have purchased this offering to date, both in and outside of Ohio, including persons claimed on all previous Form 3-Qs filed in connection with this offering.
8.(a) List any commissions, discounts, or other remuneration paid or to be paid or given to any person,
directly or indirectly, for sales in Ohio of the securities claimed on the Form 3-Q (if none, please state “None”). Use additional sheet if necessary.
Name and address of person
Amount of
Percentage of
receiving commission, etc.
commission, etc.
the Initial Offering Price
(b)Were above commissions, discounts, or other remuneration paid or given only to dealers or
salesmen licensed under Chapter 1707 of the Revised Code?
YES
NO
9.Was an offering circular used in connection with the sales reported on this Form 3-Q?
If yes,
Copy attached or
Previously submitted
10. Has this offering been terminated? YES
If yes, date of termination
11.Incorporated issuers not domiciled in this state or unincorporated issuers having a situs of its principal place of business outside this state must file a Form 11 or Form U-2. (See section 1707.11, R.C.)
SIGNATURE
The undersigned represents that the foregoing information is true as of the date hereof and agrees that this report shall be considered a written statement used for the purpose of selling securities in Ohio within the meaning of Section 1707.44(B) of the Ohio Revised Code. The individual signing this report on behalf of the issuer further represents that he/she is duly authorized by the issuer to execute and file this report.
Issuer or Dealer
(Full Name)
(Signature)
(Official Capacity)
The Division suggests Form 3-Q be sent certified mail for verification of receipt or send a copy of this form together with a self-addressed, stamped envelope.
Updated 4/11/19
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