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UNITED STATES 

SECURITIES AND EXCHANGE COMMISSION 

Washington, D.C. 20549 

FORM 1-Z 

OMB APPROVAL 

OMB Number: 3235-0723 

Expires: December 31, 2024 

Estimated average burden 

hours per response . . . . . . . 1.50 

EXIT REPORT UNDER REGULATION A 

GENERAL INSTRUCTIONS 

(1) The following information must be provided in the XML-based Form 1-Z available through the EDGAR 

portal. The format shown below may differ from the electronic version available on EDGAR. 

(2) An issuer filing this Form pursuant to Rule 257(a) must only complete the Preliminary Information and Part 

I. 

(3) An issuer filing this Form to suspend its duty to file reports under Rule 257(d) must complete the Preliminary Information and Part II. Such issuer must also provide Part I if it has not previously provided the Part I 

information in a Form 1-K filing.

* * * * * * 

PRELIMINARY INFORMATION 

Exact name of issuer as specified in the issuer’s charter: _____________________________________

Address of Principal Executive Offices: __________________________________________________

Phone: ( ) ____________________________

Commission File Number(s): _________________________________________________________

PART I 

Summary Information Regarding the Offering and Proceeds

Date of qualification of the offering statement:______________________________

Date of commencement of the offering: ___________________________________

Amount of securities qualified to be sold in the offering:______________________

Amount of securities sold in the offering:__________________________________

Price per security: $____________________________________

The portion of aggregate sales attributable to securities sold on behalf of the issuer:

$______________________

Persons who are to respond to the collection of information contained in this form are not 

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The portion of aggregate sales attributable to securities sold on behalf of selling securityholders: 

$_______________________________

Fees in connection with this offering and names of service providers:

Name of Service Provider Fees

Underwriters: _____________________ $__________________

Sales Commissions: _____________________ $__________________

Finders’ Fees: _____________________ $__________________

Audit: _____________________ $__________________

Legal: _____________________ $__________________

Promoters: _____________________ $__________________

Blue Sky Compliance: _____________________ $__________________

CRD Number of any broker or dealer listed: _______________________________

Net proceeds to the issuer: $ ____________________________________________

Clarification of responses (if necessary): __________________________________

PART II 

Certification of Suspension of Duty to File Reports

Title of each class of securities covered by this Form _________________________

Commission File Number(s)_____________________________________________

Approximate number of holders of record as of the certification date: ____________

Pursuant to the requirements of Regulation A, _________________________ (Name of issuer as specified in 

charter) certifies that it meets all of the conditions for termination of Regulation A reporting specified in Rule 

257(d) and that there are no classes of securities other than those that are the subject of this Form 1-Z regarding 

which the issuer has Regulation A reporting obligations. ______________________ (Name of issuer as specified in charter) has caused this certification to be signed on its behalf by the undersigned duly authorized person. 

By: __________________________ Date: ______________________________

Title: _________________________

Instruction: This Part II of Form 1-Z is required by Rule 257(d) of Regulation A. An officer of the issuer or any 

other duly authorized person may sign, and must do so by typed signature. The name and title of the person 

signing the form must be typed or printed under the signature. The signatory to the filing must also manually 

sign a signature page or other document authenticating, acknowledging or otherwise adopting his or her signature that appears in the filing. Such document must be executed before or at the time the filing is made and must 

be retained by the issuer for a period of five years. Upon request, the issuer must furnish to the Commission or 

its staff a copy of any or all documents retained pursuant to this instruction.

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