1. 1. Name of Applicant:
2. 2. Name under which business is conducted, if different from above:
3. 3. Address of actual location of principal place of business:

4. No. and Street

   City

   State

   ZIP Code

5. 4. State the reason for surrendering the license:

6. 5. Does the applicant owe any money or securities to any investor?

   ( ) Yes

   ( ) No

   If answer is “yes”, furnish all of the following information:

7. a. Amount of money owed: $

   1. b. Arrangements made for the payment of the money owed:
8. c. Market value of securities (if applicable):
9. d. Arrangements made for the return or delivery of securities:

10. 6. Has applicant assigned any of its contracts to another person?

    ( ) Yes

    ( ) No

    If answer is “yes” furnish all of the following information:

11. a. Name and business address of the person(s) to whom the contracts were assigned:
12. b. Name of contact person:
13. c. What alternative was provided with respect to those investors who did not consent to the assignment of their contracts?

14. 7. Is applicant involved in any legal action or proceeding?

    ( ) Yes

    ( ) No

    If “yes”, furnish complete information with respect to each.

15. 8. Are there any unsatisfied judgments or liens against applicant?

    ( ) Yes

    ( ) No

    If “yes”, furnish complete information with respect to each.

16. 9. If the answer was “yes” to any questions in paragraphs 5, 6, 7, or 8 above, attach a statement of financial condition. The Statement of financial condition must be prepared in accordance with generally accepted accounting principles and must have been prepared within 10 days of filing this application. Securities of the applicant in which applicant has an interest must be listed in a separate schedule at market price, if any; and if no current independent market exists the basis upon which value has been assigned should be stated.
17. 10. Attach a copy of the closing audit. The closing audit must be performed by an independent certified public accountant and must contain a statement specifying all deficiencies, if any, noted by the accountant, with respect to all collections and disbursements of funds, together with such information as the accountant may wish to include (such as corrective steps taken with respect to any deficiency so noted), or stating that no deficiencies were found.
18. 11. Furnish below the name and address of the person who has or will have custody or possession of applicant's books and records which are required to be preserved pursuant to Rules 280.650, 280.651, and 280.652 of Title 10 of the California Code of Regulations.

19. 12. The applicant has duly caused this application to be signed on its behalf by the undersigned, thereunder duly authorized.

    ________________________________________

    (Applicant)

    By: ______________________________________

    ________________________________________

    (Title)

    I certify or (declare) under penalty of perjury under the laws of the State of California that I have read this application and the exhibits thereto an know the contents thereof, and that the statements therein are true and correct.

    Executed at ___________________________________(Place), on _________________________(Date)

An application requesting approval to surrender a license as a capital access company shall be made on the following form:

File No. __________

Date of Application __________

COMMISSIONER OF BUSINESS OVERSIGHT STATE OF CALIFORNIA APPLICATION FOR REQUESTING APPROVAL TO SURRENDER CAPITAL ACCESS COMPANY LAW LICENSE PURSUANT TO SECTION 28650 OF THE CORPORATIONS CODE

The Application for Requesting Approval to Surrender a Capital Access Company Law License MUST BE TYPEWRITTEN and may only be filed in the Sacramento Office of the Department of Business Oversight.

Note: Authority cited: Section 28650, Corporations Code. Reference: Sections 28650 and 28651, Corporations Code.

History

1. New article 3 (section 280.200) and section filed 6-24-99; operative 7-1-99 pursuant to Government Code section 11343.4(d) (Register 99, No. 26).

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