Supplemental FOCI Data Sheet
PROVIDE RESPONSES
TO THE QUESTIONS IDENTIFIED BELOW:
(SUPPLEMENTAL PAGES MAY BE ATTACHED TO PROVIDE COMPLETE AND
ACCURATE RESPONSES.)
1. Identify organizational structure: (
)corporation,
( )sole proprietorship, (
)limited partnership,
( )general partnership, (
)other - if so, identify.
2. Current legal company or
organization name and street address:
______________________________________________________
3. Other business names used
(i.e. dba [doing business as]):
______________________________________________________
4. Date business was
incorporated or established and state:
______________________________________________________
5. Enclose a copy of your
organization's articles of incorporation, partnership
agreement (or similar documentation), and any amendments.
6.
Enclose a copy of your organization's bylaws, or similar document,
that affects the following: appointment of officers or
directors, any amendments to the number of officers or directors,
the amount and distribution of stock, or ownership, etc., and any
amendments affecting those areas. Include amendments
identifying specific individuals appointed as officers or
directors.
7. Stock ownership: (
)privately held, ( )publicly traded. If privately held include a
list of stockholders, certified by the corporate Secretary.
- Number of shares authorized:
____________________
- Number if shares
issued:_________________________
- Is cumulative voting
authorized?_________________
8. Address and phone number for the point of
contact for FOCI matters.
- Point of
Contact:______________________________________
-
Address:_______________________________________________
-
Telephone:_____________________________________________
9. Name(s) of all tier parent organizations,
if applicable:
10. How many positions of Director are
authorized? ________
11. Who is
assigned as Chairman of the Board? ____________
12. Are any of your officers directories
representatives of a foreign interest (RFI)? If so, this individuals
who require security clearances must complete the attached RFI
statement.
YES ( ) NO ( )
13. Financial
information to be provided: If privately held, an audited
financial statement less than one year old. If publicly held, the
most recent Annual Report & 10K Report, most recent proxy statement
for the annual meeting of stockholders and any Schedule 13D and/or
13G received from any beneficial owners (foreign or domestic)
who hold 5 percent or more of any class of the U.S. organization's
securities.
(Revised 3/99)
Last Modified: February 4, 2008
Please forward all questions about this site to:
Michelle Holbrook
|
