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«FORM FUNDING PORTAL APPLICATION OR AMENDMENT TO APPLICATION FOR REGISTRATION OR WITHDRAWAL FROM REGISTRATION AS FUNDING PORTAL UNDER THE SECURITIES ...»

-- [ Page 1 ] --

OMB

OMB Number: 3235-0727

SECURITIES AND EXCHANGE

Expiration Date: 1/31/2019

COMMISSION Estimated average burden

hours per response: 2.75

Washington, D.C. 20549

FORM FUNDING PORTAL

APPLICATION OR AMENDMENT TO APPLICATION FOR REGISTRATION OR

WITHDRAWAL FROM REGISTRATION AS FUNDING PORTAL UNDER THE

SECURITIES EXCHANGE ACT OF 1934 WARNING: Failure to complete this form truthfully, to keep this form current and to file accurate supplementary information on a timely basis, or the failure to keep accurate books and records or otherwise to comply with the provisions of law applying to the conduct of business as a funding portal, would violate the Federal securities laws and may result in disciplinary, administrative, injunctive or criminal action.

Check the appropriate box:

This is:

□ an initial application to register as a funding portal with the SEC.

□ an amendment to any part of the funding portal’s most recent Form Funding Portal, including a successor registration.

□ a withdrawal of the funding portal’s registration with the SEC.

Schedule A must be completed as part of all initial applications. Amendments to Schedule A must be provided on Schedule B. Schedule C must be completed by nonresident funding portals.

If this is a withdrawal of a funding portal’s registration, complete Schedule D.

If this is an amendment to any part of the funding portal’s most recent Form Funding Portal,

provide an explanation describing the amendment:

Item 1 – Identifying Information Exact name, principal business address, mailing address, if different, and contact information of

the funding portal:

A. Full name of the funding portal: __ B.

Name(s)/Website URL(s) under which business is conducted, if different from Item 1A:

C. IRS Empl. Ident. No.:

D. If a name and/or website URL in (1A) or (1B) has changed since the funding portal’s most recent Form Funding Portal, enter the previous name and/or website URL and specify whether the name change is of the □ funding portal name (1A), or □ name/website URL (1B).

Previous name(s) or website URL(s): __

E. Funding portal’s main street address (Do not use a P.O. Box):

F. Mailing address(es) (if different) and office locations (if more than one):

G. Contact Information:

Telephone Number:

Fax Number:

Email Address:

H. Contact Employee Information:

Name:

Title:

Direct Telephone Number:

Fax Number:

Direct Email Address:

I. Month applicant’s fiscal year ends:

J. Registrations Was the applicant previously registered on Form Funding Portal as a funding portal or with the Commission in any other capacity?

–  –  –

K. Foreign registrations (1) Is the applicant registered with a foreign financial regulatory authority?

Answer “no” even if affiliated with a business that is registered with a foreign financial regulatory authority.

□ Yes □ No

–  –  –

(2) List the name, in English, of each foreign financial regulatory authority and country with which the applicant is registered. A separate entry must be completed for each foreign financial regulatory authority with which the applicant is registered.

English Name of Foreign Financial Regulatory Authority:

–  –  –

B. If other than a sole proprietor, indicate date and place applicant obtained its legal status (i.e., state or country where incorporated, where partnership agreement was

filed, or where applicant entity was formed):

–  –  –

Do not report previous successions already reported on Form Funding Portal. If “yes,” complete Section 3.B. below.

B. Complete the following information if succeeding to the business of a currentlyregistered funding portal. If the applicant acquired more than one funding portal in the succession being reported on this Form Funding Portal, a separate entry must be completed for each acquired firm.

Name of Acquired Funding Portal:

–  –  –

Item 4 – Control Relationships In this Item, identify every person that, directly or indirectly, controls the applicant, controls management or policies of the applicant, or that the applicant directly or indirectly controls.

If this is an initial application, the applicant also must complete Schedule A. Schedule A asks for information about direct owners and executive officers. If this is an amendment updating information reported on the Schedule A filed with the applicant’s initial application, the applicant must complete Schedule B.





Item 5 – Disclosure Information

In this Item, provide information about the applicant’s disciplinary history and the disciplinary history of all associated persons or control affiliates of the applicant (as applicable). This information is used to decide whether to revoke registration, to place limitations on the applicant’s activities as a funding portal, and to identify potential problem areas on which to focus during examinations. One event may result in the requirement to answer “yes” to more than one of the questions below. Check all answers that apply. Refer to the Explanation of Terms section of Form Funding Portal Instructions for explanation of italicized terms.

If the answer is “yes” to any question in this Item, the applicant must complete the appropriate Disclosure Reporting Page (“DRP”) (FP) – Criminal, Regulatory Action, Civil Judicial Action, Bankruptcy/SIPC, Bond, or Judgment/Lien, as applicable.

–  –  –

If the answer is “yes” to any question below, complete a Criminal DRP.

A. In the past ten years, has the applicant or any associated person:

(1) been convicted of any felony, or pled guilty or nolo contendere (“no contest”) to any charge of a felony, in a domestic, foreign, or military court?

–  –  –

B. In the past ten years, has the applicant or any associated person:

(1) been convicted of any misdemeanor, or pled guilty or nolo contendere (“no contest”), in a domestic, foreign, or military court to any charge of a misdemeanor in a case involving: investment-related business, or any fraud, false statements, or omissions, wrongful taking of property, bribery, perjury, forgery, counterfeiting, extortion, or a conspiracy to commit any of these offenses?

–  –  –

The response to the following question may be limited to charges that are

currently pending:

(2) been charged with a misdemeanor listed in Item 5-B(1)?

–  –  –

Regulatory Action Disclosure If the answer is “yes” to any question below, complete a Regulatory Action DRP.

C. Has the SEC or the Commodities Futures Trading Commission (“CFTC”)

ever:

(1) found the applicant or any associated person to have made a false statement or omission?

–  –  –

(3) found the applicant or any associated person to have been a cause of the denial, suspension, revocation, or restriction of the authorization of an investmentrelated business to operate?

–  –  –

(5) imposed a civil money penalty on the applicant or any associated person, or ordered the applicant or any associated person to cease and desist from any activity?

–  –  –

D. Has any other federal regulatory agency, any state regulatory agency, or any

foreign financial regulatory authority:

(1) ever found the applicant or any associated person to have made a false statement or omission, or been dishonest, unfair, or unethical?

–  –  –

(3) ever found the applicant or any associated person to have been the cause of a denial, suspension, revocation, or restriction of the authorization of an investment-related business to operate?

–  –  –

(4) in the past ten years entered an order against the applicant or any associated person in connection with an investment-related activity?

–  –  –

(5) ever denied, suspended, or revoked the registration or license of the applicant or that of any associated person, or otherwise prevented the applicant or any associated person of the applicant, by order, from associating with an investmentrelated business or restricted the activities of the applicant or any associated person?

–  –  –

E. Has any self-regulatory organization or commodities exchange ever:

(1) found the applicant or any associated person to have made a false statement or omission?

–  –  –

(3) found the applicant or any associated person to have been the cause of a denial, suspension, revocation or restriction of the authorization of an investmentrelated business to operate?

–  –  –

(4) disciplined the applicant or any associated person by expelling or suspending the applicant or the associated person from membership, barring or suspending the applicant or the associated person from association with other members, or by otherwise restricting the activities of the applicant or the associated person?

–  –  –

F. Has the applicant or any associated person ever had an authorization to act as an attorney, accountant, or federal contractor revoked or suspended?

–  –  –

G. Is the applicant or any associated person currently the subject of any regulatory proceeding that could result in a “yes” answer to any part of Item 5C, 5-D, or 5-E?

<

–  –  –

Civil Judicial Disclosure If the answer is “yes” to a question below, complete a Civil Judicial Action DRP.

H. Has any domestic or foreign court:

(1) in the past ten years, enjoined the applicant or any associated person in connection with any investment-related activity?

–  –  –

(2) ever found that the applicant or any associated person was involved in a violation of investment-related statutes or regulations?

–  –  –

(3) ever dismissed, pursuant to a settlement agreement, an investment- related civil action brought against the applicant or any associated person by a state or foreign financial regulatory authority?

–  –  –

I. Is the applicant or any associated person now the subject of any civil proceeding that could result in a “yes” answer to any part of Item 5-H(1)-(3)?

–  –  –

Financial Disclosure If the answer is “yes” to a question below, complete a Bankruptcy/Disclosure, Bond Disclosure or Judgment/Lien DRP, as applicable.

J. In the past ten years, has the applicant or a control affiliate of the applicant

ever been a securities firm or a control affiliate of a securities firm that:

(1) has been the subject of a bankruptcy petition?

–  –  –

If “yes,” briefly describe the non-securities business.

Item 7 – Qualified Third Party Arrangements; Compensation Arrangements A. Qualified Third Party Arrangements. Complete the following information for each person that will hold investor funds in escrow or otherwise pursuant to the requirements of Rule 303(e) of Regulation Crowdfunding (17 CFR 227.303(e)).

–  –  –

B. Compensation. Please describe any compensation arrangements funding portal has with issuers.

EXECUTION The funding portal consents that service of any civil action brought by or notice of any proceeding before the Securities and Exchange Commission or any self-regulatory organization in connection with the funding portal’s investment-related business may be given by registered or certified mail to the funding portal’s contact person at the main address, or mailing address, if different, given in Items 1.E., 1.F., and 1.H. If the applicant is a nonresident funding portal, it must complete Schedule C to designate a U.S. agent for service of process.

The undersigned represents and warrants that he/she has executed this form on behalf of, and is duly authorized to bind, the funding portal. The undersigned and the funding portal represent that the information and statements contained herein and other information filed herewith, all of which are made a part hereof, are current, true and complete. The undersigned and the funding portal further represent that, if this is an amendment, to the extent that any information previously submitted is not amended, such information is currently accurate and complete.

Date:

Full Legal Name of Funding Portal:

–  –  –

Title:

FORM FUNDING PORTAL

SCHEDULE A Direct Owners and Executive Officers

1. Complete Schedule A only if submitting an initial application. Schedule A asks for information about the applicant’s direct owners and executive officers. Use Schedule B to amend this information.

2. Direct Owners and Executive Officers. List below the names of:



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