Act Of 1972 For Retroactive Registration Of Investment Company Securities {210}

FORM 210 (Instruction Sheet) PENNSYLVANIA DEPARTMENT OF BANKING AND SECURITIES CORPORATION FINANCE OFFICE 17 N 2ND ST, STE 1300 HARRISBURG, PA 17101-2290 (717) 787-8059 ***** APPLICATION UNDER SECTION 210 OF THE PENNSYLVANIA SECURITIES ACT OF 1972 FOR RETROACTIVE REGISTRATION OF INVESTMENT COMPANY SECURITIES NOTE: Under regulation 603.011, a document is not deemed filed with the Pennsylvania Department of Banking and Securities ("Department") unless complete and properly executed in all material respects. WHO MAY FILE: Only issuers that are open-end or closed-end investment companies, face amount certificate companies or unit investment trusts as those persons are classified in the Investment Company Act of 1940 ("Investment Companies") that had an effective registration under Section 205 or 206 of the Pennsylvania Securities Act ("1972 Act") at the time the securities which are the subject of this application were sold in Pennsylvania. WHEN TO FILE: Form 210 must be filed within 24 months from the date of the first sale of securities intended to be covered by this application occurred in Pennsylvania. OTHER CONDITIONS: The provisions of Section 210 are not available if, at the time Form 210 is filed with the Department, the Investment Company: 1. Is the subject of a civil, criminal, or administrative proceeding alleging violations of Section 201 of the 1972 Act; or 2. Fails to attach to this Form a check made payable to the "Commonwealth of Pennsylvania" in the amount prescribed by Section 602.1(d) of the 1972 Act (see also Item 10 of Form 210). NOTE: Under 64 Pa. Code § 604.011, a facsimile transmission of any materials to the Department does not constitute a filing with the Department. FORM 210 REVISED: 3/01/2016 1 American LegalNet, Inc. www.FormsWorkFlow.com General Instructions 1. One manually signed copy, and one photocopy of the Form and two copies of all attachments shall be filed with the Department's Harrisburg Office. If mailed, it is advisable to send it by registered or certified mail, postage prepaid, return receipt requested. 2. Typewrite or print all answers in the space provided. Answer each item completely. An answer of "not applicable" is inappropriate. If the space is insufficient, attach a schedule to the Form and make reference to each item included in the schedule. 3. This Form shall be manually signed by the issuer. If the issuer is a corporation, it should be signed in the name of the corporation by an executive officer duly authorized; if a partnership, it should be signed in the name of the partnership by a general partner; and if an unincorporated association or other organization not a partnership, this Form should be signed in the name of such organization by a person responsible for the direction or management of its affairs. 4. In the event, that at any time from the date of the filing of the Form with the Department until the granting or denial of the application, any material statement made in the Form or in any attachment thereto becomes incorrect or inaccurate in any material respect, the issuer shall file an amendment with the Department on Form AM within 5 business days of the occurrence of the event which required the filing of such amendment. 5. In lieu of answering any specific question in the Form, the issuer may incorporate by reference information contained in any document attached thereto or previously on file with the Department. Any such reference should be to the page and paragraph number or other specified portion of the document where the information is located. 6. The appropriate oversale assessment required by Section 602.1(d) shall accompany the filing of this Form and must be received before an application for retroactive registration can be granted. 7. If retroactive registration is granted, the securities sold during the period described in Item 6 of the Form will be deemed to be registered retroactive to the date of the initial registration. 8. Please remove this instruction sheet before filing this Form. EACH PERSON COMPLETING THIS FORM OR PROVIDING INFORMATION TO BE INCLUDED IN THIS FORM SHOULD BE FAMILIAR WITH THE PENALTIES CONTAINED IN THE ACT, AND ALL REGULATIONS ADOPTED THEREUNDER, FOR MAKING FALSE OR INCOMPLETE STATEMENTS IN CONNECTION WITH THE SALE OF A SECURITY OR IN ANY FILING WITH THE DEPARTMENT. FORM 210 REVISED: 3/01/2016 2 American LegalNet, Inc. www.FormsWorkFlow.com FORM 210 PENNSYLVANIA DEPARTMENT OF BANKING AND SECURITIES CORPORATION FINANCE OFFICE APPLICATION UNDER SECTION 210 OF THE PENNSYLVANIA SECURITES ACT OF 1972 FOR RETROACTIVE REGISTRATION OF INVESTMENT COMPANY SECURITIES 1. 2. 3. 4. Exact Name of Investment Company: Address: Contact Person: Telephone: 5. Fax: Registration Information 6. State the time period during which the securities intended to be covered by this application for retroactive registration were sold in Pennsylvania: 7. Describe the securities and the amount sold in Pennsylvania during the time period described in Item 6 above: 8. What was the Investment Company's Pennsylvania registration file number for the period described in Item 6 above? Civil, Criminal or Administrative Proceedings 9. As of the date filing Form 210 with the Department, is the Investment Company identified in Item 1 the subject of any civil, criminal or administrative proceeding for violation of Section 201 of the 1972 Act for the securities described in Item 7: YES NO If the response is YES, the retroactive registration provisions of Section 210 are not available to the applicant. Calculation of Oversale Assessment Payable 10. Using the fee schedule in Section 602.1(b) of the 1972 Act, determine the amount of fees payable to the Department based upon the total amount of securities sold (registered and oversold securities) during the effective registration period in Pennsylvania that included the time period described in Item 6. Enter Fee Payable Amount Here: $ 11. Enter the aggregate amount of fees paid by the Investment Company (including any fees paid in connection with amendment filings) during the effective registration period in Pennsylvania that included the time period described in Item 6. Enter Total Amount of Fees Paid Here $ FORM 210 REVISED: 3/01/2016 3 American LegalNet, Inc. www.FormsWorkFlow.com 12. The oversale assessment is three times the difference between Item 10 and 11. If the oversale assessment is less than $350, the oversale assessment due is $350. If the oversale assessment is gr