Form 5 - Start-up Crowdfunding – Report of Exempt Distribution GENERAL INSTRUCTIONS: (1) This report must be typed, printed, signed, and filed with the securities regulatory authority or regulator of each of the participating jurisdictions where the issuer has made a start-up crowdfunding distribution, as well as with the securities regulatory authority or regulator in the issuer’s head office jurisdiction at the address(es) provided on the last page of this form no later than the 30th day after the closing of the distribution. Issuers must also file the offering document no later than the 30th day after the closing of the distribution. (2) References to a purchaser in this report are to the beneficial owner of the securities. (3) This form must be completed and certified by an authorized individual on behalf of the issuer. (4) For issuer information, please refer to the Start-up Crowdfunding Guide for Businesses available on the website of the securities regulatory authority or regulator of the participating jurisdictions. ISSUER INFORMATION 1. Full legal name: Former legal name (if the name has changed since last report): Head office address: Telephone: Fax: Website URL: 2. Full legal name of contact person: Business address: Telephone: Fax: E-mail: Position with issuer
3. Indicate the industry of the issuer by checking the appropriate box: ☐ Bio-tech ☐ Hi-tech ☐ Oil and gas ☐ Financial Services ☐ Industrial ☐ Real estate ☐ Forestry ☐ Mining ☐ Utilities ☐ Other (describe): START-UP CROWDFUNDING DISTRIBUTION 4. Date the offering document was first made available to purchasers through the funding portal: Date of the closing of the distribution: 5. Type of eligible securities offered: 6. If the eligible securities offered are convertible, describe the type of underlying security, the terms of conversion and any expiry date: 7. Total number of eligible Price per securities distributed: eligible security ($): 8. Aggregate funds raised through this distribution ($): 9. Total commission, fee and any other amount paid to the funding portal for this distribution ($): 10. Complete Schedule 1 to this report.
11. Complete the following table for each participating jurisdiction where purchasers of the securities reside. Each participating Number of Total funds raised from jurisdiction where purchasers purchasers in the purchasers reside jurisdiction ($) Total number of purchasers Total funds raised from purchasers in all the participating jurisdictions ($) CERTIFICATE On behalf of the issuer, I certify that the statements made in this report are true and complete. Full legal name of issuer: Signature: Date: Print name: Position held: Telephone: E-mail: IT IS AN OFFENCE TO MAKE A MISREPRESENTATION IN THIS REPORT
NOTICE - COLLECTION AND USE OF PERSONAL INFORMATION The personal information required under this report is collected on behalf of and used by the securities regulatory authorities or, where applicable, the regulators of the participating jurisdictions under the authority granted in securities legislation for the purposes of the administration and enforcement of the securities legislation. If you have any questions about the collection and use of this information, contact the securities regulatory authority or, where applicable, the regulator in each of the participating jurisdictions where the report is filed, at the address(es) listed at the end of this report.
SCHEDULE 1 - PURCHASER INFORMATION Provide the information below for each purchaser who purchased eligible securities through the start-up crowdfunding distribution. Use an attachment if necessary. This information will not be placed on the public file of the securities regulatory authority or regulator of the participating jurisdictions. However, freedom of information legislation may require a securities regulatory authority or regulator of a participating jurisdiction to make this information available if requested. Full Residential Province / Telephone, E-mail Number of Total legal address, territory including eligible purchase name including area code securities price ($) number, purchased street, city and postal code
Securities regulatory authorities and regulators of the participating jurisdictions: Manitoba The Manitoba Securities Commission 500 – 400 St Mary Avenue Winnipeg, Manitoba R3C 4K5 Telephone: 204-945-2548 Toll free in Manitoba: 1-800-655-2548 E-mail: Exemptions.msc@gov.mb.ca www.msc.gov.mb.ca New Brunswick Financial and Consumer Services Commission 85 Charlotte Street, Suite 300 Saint John, New Brunswick E2L 2J2 Toll free: 1-866-933-2222 Fax: 506-658-3059 E-mail: info@fcnb.ca www.fcnb.ca Nova Scotia Nova Scotia Securities Commission Suite 400, 5251 Duke Street Halifax, Nova Scotia B3J 1P3 Telephone: 902-424-7768 Toll free in Nova Scotia: 1-855-424-2499 Fax: 902-424-4625 E-mail: nssc.crowdfunding@novascotia.ca www.nssc.gov.ns.ca Québec Autorité des marchés financiers Direction du financement des sociétés 800, rue du Square-Victoria, 22nd floor P.O. Box 246, Tour de la Bourse Montréal, Québec H4Z 1G3 Telephone: 514-395-0337 Toll free in Québec: 1-877-525-0337 Fax: 514 873-3090 E-mail: financement-participatif@lautorite.qc.ca www.lautorite.qc.ca Saskatchewan Financial and Consumer Affairs Authority of Saskatchewan Securities Division Suite 601 - 1919 Saskatchewan Drive Regina, Saskatchewan S4P 4H2 Telephone: 306-787-5645 Fax: 306-787-5842 E-mail: exemptions@gov.sk.ca www.fcaa.gov.sk.ca
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