Appendix A to Part 197 - Form for Securities Sale Report

Appendix A to Part 197 - Form for Securities Sale Report

Office of the Comptroller of the Currency

[Form G-12]

Securities Sale Report Pursuant to § 197.12

OCC No.

Issuer's Name:

Address:

If in organization, state the date of FDIC certification of insurance of accounts: ____

State the title, number, aggregate and per-unit offering price of the securities sold: ____

State the aggregate and per-unit dollar amounts of actual itemized offering expenses, discounts, commissions, and other fees: ____

State the aggregate and per-unit dollar amounts of the net proceeds raised: ____

Describe the use of proceeds. If unknown, provide reasonable estimates of the dollar amount allocated to each purpose for which the proceeds will be used: ____

State the number of purchasers of each class of securities sold and the number of owners of record of each class of the issuer's equity securities at the close or termination of the offering: ____

For a non-public offering, also state the factual and legal grounds for the exemption claimed (attach additional pages if necessary): ____

For a non-public offering, all offering materials used should be listed: ____

Person to Contact:

Telephone No.:

This issuer has duly caused this securities sale report to be signed on its behalf by the undersigned person.

Date of securities sale report

Issuer:

Signature:

Name:

Title:

Instruction: Print the name and title of the signing representative under his or her signature. Ten copies of the securities sale report should be filed, including one copy manually signed, as required under 12 CFR 197.5.

Attention

Intentional misstatements or omissions of fact constitute violations of Federal law (see 18 U.S.C. 1001 and 12 CFR 197.180(b)).