1. (a) An acquiring or converting entity in an exchange under Section 25103(h) of the Code shall file a Notice of Exchange Transaction with the Commissioner no later than 15 calendar days after the first sale of the securities in the transaction in this state. No notice is required to be filed if there is no sale in this state.

2. (b) The notice referred to in subdivision (h) of Section 25103 of the Code shall be in the following form:

   (Department of Business Oversight Use Only)

   Department of Business Oversight File No., if any

   Fee Paid $

   Receipt No.

   (Insert File Number(s) of Previous Filings Before the Department, if any)

   FEE: $600

   (See Corporations Code Section 25608(z))

   COMMISSIONER OF BUSINESS OVERSIGHT STATE OF CALIFORNIA

   NOTICE OF EXCHANGE TRANSACTION OR ENTITY CONVERSION PURSUANT TO CORPORATIONS CODE SECTION 25103(h)

3. 1. Name of acquiring or converting entity (entity resulting from the conversion):

4. 2. (a) Address of acquiring or converting entity:

   Street

   City

   State

   ZIP

5. (b) Mailing address:

   Street

   City

   State

   ZIP

6. (c) Area code and telephone number:
7. 3. Acquiring or converting entity's state or other jurisdiction of incorporation or organization:
8. 4. (a) Name of entity to be acquired or converted:
9. (b) State or jurisdiction of incorporation or organization of entity to be acquired or converted:

10. 5. The exchange of securities meets the requirements of (check one):

    ( ) Section 25103(h)(1)(A) of the Code.

    ( ) Section 25103(h)(1)(B) of the Code, and the state of incorporation or organization is ____________________, or the form of the organization is .

11. 6. Type of filing under the Securities Act of 1933, if applicable:

12. 7. Date of Notice: ____________________

    ( )

    Check if acquiring or converting

    Acquiring or converting entity

    entity has a consent to service of

    process on file with the

    Commissioner

    Authorized signature on behalf of acquiring or converting entity

    Print Name and Title of Signatory

    Name, Address and Phone Number of Contact Person:

    Instructions: Each acquiring or converting entity (other than a California corporation) filing a notice under Section 25103(h) must file a consent to service of process (Form 260.165), unless it already has a consent to service on file with the Commissioner.

    260.103.6 (9/09)

Note: Authority cited: Sections 25165 and 25610, Corporations Code. Reference: Sections 25103(h), 25165 and 25608(z), Corporations Code.

History

1. New section filed 12-7-90; operative 1-1-91 (Register 91, No. 3).

2. Amendment of section, form and Note filed 5-20-97; operative 5-20-97 pursuant to Government Code section 11343.4(d) (Register 97, No. 21).

3. Amendment of section and Note filed 9-23-2009; operative 10-23-2009 (Register 2009, No. 39).

4. Change without regulatory effect amending form within subsection (b) filed 8-13-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 33).