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.

  1. Number of shares authorized: ____________________
  2. Number if shares issued:_________________________
  3. 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)

 

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Last Modified: February 4, 2008
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