EFD State Fee Settings Form

/ Electronic Filing Depository System Entitlement
& Settings Form
Form D, Rule 506 Configuration

☐ Click here if is this is an update to a previously submitted Form

Section 1 - Jurisdiction: Click here to enter text.

Section 2 - Electronic Filing Depository (“EFD”) System Jurisdiction Participation Acknowledgement

If your jurisdiction will be using the EFD System please complete all of the requested information and return the completed form.

FOR NON-PARTICIPATING JURISDICTIONS ONLY
If your jurisdiction will NOT utilize the EFD System for purposes of collecting Form D filings for Regulation D, Rule 506 offerings at this time, simply check the box below, sign and return the form. Do not complete the remainder of the form. If the jurisdiction does not participate in the EFD System for Regulation D, Rule 506 notice filings the functionality will be disabled for the jurisdiction (i.e. “greyed out.”)
☐ Click here to enter text. will not be using EFD for Form D filings for Regulation D, Rule 506 offerings at this time.
______
Signature / ______
Title
______
Print Name / ______
Date

An initial, electronically signed (simply type your full name) copy may be sent to Jason Wolf () and the original, executed form should also be mailed to:

North American Securities Administrators Association, Inc.
c/o Jason Wolf
750 First Street, NE
Suite 1140
Washington, DC 20002-4251

Definitions

Offering Amount: This is the total offering amount in your state.[1] This information is entered by the user during the state specific sales report data collection screen during the filing process. This value is sometimes used as a factor in state fee calculations.

Sold Amount: This is the total dollar amount sold in your state to date. This information is entered by the user during the state specific sales report data collection screen during the filing process. This value is sometimes used as a factor in state fee calculations.

State Super Account Administrator: The individual in a jurisdiction with the authority to execute system settings and entitlement forms (usually the state securities administrator).

Termination: An offering that was being made and now the offering is beingterminated in your state.

Total Sales: This is a count of the number of sales in your state to date. This information is entered by the user during the state specific sales report data collection screen during the filing process.

Withdrawal: An offering with zero “Sold Amount” in your state that is being withdrawn.

THERE ARE DROP DOWN FIELDS IN THIS DIGITAL FORM THAT MUST BE FILLED IN CORRECTLY.

Section 3 – State Super Account Administrator Information

State Super Account Administrator (respond to each item)

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Electronic Filing Depository Settings Form
Form D Configuration
Name / Click here to enter text.
Title / Click here to enter text.
Phone / Click here to enter text.
Email / Click here to enter text.
Requested User Name / Click here to enter text.

Regulator Contact (Shown on EFD website State Regulator Contact Page)

Page | 1

Electronic Filing Depository System Entitlement
& Settings Form
Form D, Rule 506 Configuration
Name / Click here to enter text.
Title / Click here to enter text.
Phone / Click here to enter text.
Email / Click here to enter text.

Group Email Address (Optional)

Group Email Address to receive reports / Click here to enter text.

Section 4 - State Sales Report Data Collection

Collect Offering Amount (Dollars) / Choose an item.
Collect Date of First Sale (in your State) / Choose an item.
Collect Total Sales (Count) / Choose an item.
Collect Sold Amount (Dollars) / Choose an item.

Please remember that if fees are based on Offering Amount or Sold Amount then these fields must be marked as either “Optional” or “Required.”

Section 5 - Filing Review Methods

Specify Processing Method for each Notice Filing Type:

New Notice Filings / Choose an item.
Other Active Notice Types (Form D Amendments, Annual Amendments, non-Annual Amendments, Annual Sales Reports, non-Annual Sales Reports)
-Even if your state does not require these types of notices, choosing “Automatic System Process” means that these notices will simply be filed away automatically for you. / Choose an item.
Withdrawal Notice Filings / Choose an item.
Termination Notice Filings / Choose an item.

Specify Filing Requirements in your Jurisdiction:

Does your state require an annual amendment?
-EFD will automatically set expiration dates on new filings based on the anniversary of the notice filing in your state.
-EFD will Email weekly summary reports to your group email that will show offering notices in your state that have expired.
-Publicly, notices will be shown as “EXPIRED” if an annual sales report/ annual renewal / annual amendment is not filed. / Choose an item.

Lifetime Maximum Fee Handling:

Do offerings in your State have a Maximum Lifetime Fee?
-Some states calculate fees for new notices based on a percentage, and then continue to combine fees for amendments until a certain lifetime maximum fee is reached. / Choose an item.
Enter the Maximum Lifetime Fee Amount / Click here to enter text.

Section 6 - New Notice Filing Fees

Fees

Are Fees collected for New Notices / Choose an item.

Fixed Fee

Fee Amount / Click here to enter text.

Variable Fees (can be combined with a fixed fee (Fixed + Sum of Variable Fees))

Minimum Fee / Click here to enter text.
Maximum Fee / Click here to enter text.

Start Range ($)

Stop Range ($)

Percentage as Decimal (1% = .01)

EDGAR (Offering or Sold Amount) orState (Offering or Sold Amount)

Choose an item.

*Enter EDGAR Offering, EDGAR Sold Amount, State Offering or State Amount Sold in the right most column of the grid above.

Variable Fee Calculations (Check those that apply):

☐ Is the Maximum fee not to exceed SUM(Variable Fees) + Fixed Fee?

☐ Should the SUM (Variable Fees) not exceed the Maximum Fee and then add the Fixed Fee to calculate the total to be charged?

New Notice LATE Fees

Are Late Fees collected for New Notices? / Choose an item.

Fee Matrix (can be combined with a fixed fee (Fixed + Sum of Variable Fees))

Minimum Fee / Click here to enter text.
Maximum Fee / Click here to enter text.

Start Range (days)

Stop Range (days)

Fixed Fee (or use next column to define percentage)

Percentage as Decimal (1% = .01)

EDGAR (Offering or Sold Amount) orState (Offering or Sold Amount)To Be used with the Percentage Column

Choose an item.

Variable Fee Calculations (Check those that apply):

☐ Is the Maximum fee not to exceed SUM(Variable Fees) + Fixed Fee?
☐ Should the SUM (Variable Fees) not exceed the Maximum Fee and then add the Fixed Fee to calculate the total to be charged?
For example, are the fees capped as a total or are the variable fees capped themselves?

☐ Are Days in the grid above based on Date of 1st Sale?
☐ Are Days in the grid above based on EDGAR filing Date?

Multi-Year Filing Fee Discounts

Allow Multi-Year Notices: / Choose an item.
Maximum Years Allowed: / Click here to enter text.
Amount Discounted per year: / Click here to enter text.

Section 7 - Amendment Notice/Non-Annual Sales Report Fees

Fees

Are Fees collected for Amendment Notices/ Non-Annual Sales Reports? / Choose an item.

Fixed Fee

Fee Amount / Click here to enter text.

Variable Fees (can be combined with a fixed fee (Fixed + Sum of Variable Fees))

Minimum Fee / Click here to enter text.
Maximum Fee / Click here to enter text.

Start Range ($)

Stop Range ($)

Percentage as Decimal (1% = .01)

EDGAR (Offering or Sold Amount) orState (Offering or Sold Amount)

Choose an item.

Variable Fee Calculations (Check those that apply):

☐ Is the Maximum fee not to exceed SUM(Variable Fees) + Fixed Fee?

☐ Should the SUM (Variable Fees) not exceed the Maximum Fee and then add the Fixed Fee to calculate the total to be charged?

Section 8 - Renewal/Annual Sales Report/Annual Amendment Notice Fees

Fees

Are Fees collected for Renewal/Annual Sales Report/Annual Amendment Notice? / Choose an item.

Fixed Fee

Fee Amount / Click here to enter text.

Variable Fees (can be combined with a fixed fee (Fixed + Sum of Variable Fees))

Minimum Fee / Click here to enter text.
Maximum Fee / Click here to enter text.

Start Range ($)

Stop Range ($)

Percentage as Decimal (1% = .01)

EDGAR (Offering or Sold Amount) orState (Offering or Sold Amount)

Choose an item.

*Enter EDGAR Offering, EDGAR Sold Amount, State Offering or State Amount Sold in the right most column of the grid above.

Variable Fee Calculations (Check those that apply):

☐ Is the Maximum fee not to exceed SUM(Variable Fees) + Fixed Fee?

☐ Should the SUM (Variable Fees) not exceed the Maximum Fee and then add the Fixed Fee to calculate the total to be charged?

Renewal/Annual Sales Report/Annual Amendment Notice Late Fees

Are Late Fees collected for Renewal/Annual Sales Report/Annual Amendment Notice? / Choose an item.

Fee Matrix (can be combined with a fixed fee (Fixed + Sum of Variable Fees))

Minimum Fee / Click here to enter text.
Maximum Fee / Click here to enter text.

Start Range (days)

Stop Range (days)

Fixed Fee $ (or use next column to define percentage)

Percentage as Decimal (1% = .01)

EDGAR (Offering or Sold Amount) orState (Offering or Sold Amount)

Choose an item.

*Enter EDGAR Offering, EDGAR Sold Amount, State Offering or State Amount Sold in the right most column of the grid above.

Variable Fee Calculations (Check those that apply):

☐ Is the Maximum fee not to exceed SUM(Variable Fees) + Fixed Fee?

☐ Should the SUM (Variable Fees) not exceed the Maximum Fee and then add the Fixed Fee to calculate the total to be charged?

Multi-Year Filing Fee Discounts

Allow Multi-Year Notices: / Choose an item.
Maximum Years Allowed: / Click here to enter text.
Amount Discounted per year: / Click here to enter text.

Section 9 - Termination Notice Filing Fees

Fees

Are Fees collected for Termination Notice? / Choose an item.

Fixed Fee

Fee Amount / Click here to enter text.

Variable Fees (can be combined with a fixed fee (Fixed + Sum of Variable Fees))

Minimum Fee / Click here to enter text.
Maximum Fee / Click here to enter text.

Start Range ($)

Stop Range ($)

Percentage as Decimal (1% = .01)

EDGAR (Offering or Sold Amount) orState (Offering or Sold Amount)

Choose an item.

*Enter EDGAR Offering, EDGAR Sold Amount, State Offering or State Amount Sold in the right most column of the grid above.

Variable Fee Calculations (Check those that apply):

☐ Is the Maximum fee not to exceed SUM(Variable Fees) + Fixed Fee?

☐ Should the SUM (Variable Fees) not exceed the Maximum Fee and then add the Fixed Fee to calculate the total to be charged?

Termination Notice Late Fees

Are Late Fees collected for Termination Notices? / Choose an item.

Fee Matrix (can be combined with a fixed fee (Fixed + Sum of Variable Fees))

Minimum Fee / Click here to enter text.
Maximum Fee / Click here to enter text.

Start Range (days)

Stop Range (days)

Fixed Fee (or use next column to define percentage)

Percentage as Decimal (1% = .01)

EDGAR (Offering or Sold Amount) orState (Offering or Sold Amount)

Choose an item.

Variable Fee Calculations (Check those that apply):

☐ Is the Maximum fee not to exceed SUM(Variable Fees) + Fixed Fee?

☐ Should the SUM (Variable Fees) not exceed the Maximum Fee and then add the Fixed Fee to calculate the total to be charged?

Special Instructions for handling Late Terminations (Please type below):

Section 10 - Withdrawal Notice Filing Fees

Fees

Are Fees collected for Withdrawal Notices? / Choose an item.

Fixed Fee

Fee Amount / Click here to enter text.

Variable Fees (can be combined with a fixed fee (Fixed + Sum of Variable Fees))

Minimum Fee / Click here to enter text.
Maximum Fee / Click here to enter text.

Start Range ($)

Stop Range ($)

Percentage as Decimal (1% = .01)

EDGAR (Offering or Sold Amount)

Choose an item.

Variable Fee Calculations (Check those that apply):

☐ Is the Maximum fee not to exceed SUM(Variable Fees) + Fixed Fee?

☐ Should the SUM (Variable Fees) not exceed the Maximum Fee and then add the Fixed Fee to calculate the total to be charged?

Section 11 - Other Special Considerations for your Jurisdiction: (please type below)

*NOTE: Entries on this page are for informational and discussion purposes only. The settings contained elsewhere in this Fee Settings Form set forth the fee setting functionality of the EFD System, which shall not be modified as a result of information set forth on this page.

Section 12 – Changes

If any of the information contained in this form changes, you must amend this form and send an executed copy to NASAA. Please note that any changes to the information contained in this form mayrequire 30 days to implement.

Section 13 – Entitlement Agreement and Authorization for Configuration

I, Click here to enter text.,hereby acknowledge that I am individually legally authorized to act for and on behalf of the jurisdiction identified in Section 1 of this Agreement (“Jurisdiction”) and that I am authorized to execute this agreement on behalf of that Jurisdiction.

I acknowledge and agree that my Jurisdiction designated the individual identified in Section 3, the State Super Account Administrator, (“SSAA”) for the purposes of accessing the EFD system operated by Software Consultants Services (“SCS”) on behalf of NASAA. I further acknowledge and agree that the designated SSAA, on behalf of the Jurisdiction, will ensure that only authorized employees or agents of the Jurisdiction are granted entitlement by the Jurisdiction to access and use the EFD System. In the event the SSAA terminates employment or otherwise has his or her authority rescinded by the Jurisdiction, the Jurisdiction will notify NASAA immediately in writing, and a replacement SSAA will be promptly appointed. I further acknowledge and agree that the EFD System that users entitled by my Jurisdiction may access may contain personal and/or confidential information that must be safeguarded from inadvertent loss or theft. I agree that my Jurisdiction will take affirmative steps to ensure the security of such information by generally complying, and by requiringits entitled users to comply, with appropriate state or federal laws governing the security of information.

I acknowledge and agree that my Jurisdiction and the designated SSAA from my Jurisdiction are solely responsible for obtaining, distributing, revoking and monitoring user entitlements granted by my Jurisdiction. I further acknowledge and agree that my Jurisdiction assumes full responsibility for such entitlements and actions. Without limiting the generality of the foregoing, my Jurisdiction shall immediately terminate entitlements to the EFD System, either directly via the EFD System if possible or otherwise via written notice to SCS, for any individual user: upon termination of the user’s employment or agency with the Jurisdiction, in the event the Jurisdiction becomes aware of any unauthorized use of such user’s account, or has other reason to believe the security of the account has been breached, or in the event the Jurisdiction becomes aware of or has reason to believe the EFD System has been or is being misused by the individual.

All access to and use of the applications, content, and services for which user entitlements are granted hereundershall be governed by the Electronic Filing Depository Terms of Use, which can be found at I hereby acknowledge that I have read and agree to bind my Jurisdiction and its entitled users to these Terms of Use without exception, alteration or addition. I understand that these Terms of Use may be revised and updated from time to time and that it is my responsibility to periodically review the Electronic Filing Depository Terms of Use. I agree that my Jurisdiction shall use commercially reasonable efforts to ensure that all users entitled by my Jurisdiction to access and use the EFD System comply with foregoing Terms of Use, as the same may be revised and updated from time to time, and that my Jurisdiction shall be solely responsible for any failure by such users to do so.

In order to help ensure that the EFD System is configured properly for my Jurisdiction, I am instructing NASAA, via its agent SCS, to apply the system settings set forth above for my Jurisdiction. I acknowledge that neither SCS nor NASAA will independently verify the information provided above for my Jurisdiction. I agree that my Jurisdiction will assist NASAA and SCS with any reasonably requested testing of the initial settings contained in this form, or of any subsequent revisions submitted pursuant to Section 12 above, as a condition of their implementation.

I hereby certify that the all information provided by me on behalf of my Jurisdiction in this document is true and correct to the best of my knowledge, information and belief.

______
Signature / ______
Title
______
Print Name / ______
Date

An initial,electronically signed (simply type your full name) copy may be sent to Jason Wolf () and the original, executed form should also be mailed to:

North American Securities Administrators Association, Inc.
c/o Jason Wolf
750 First Street, NE
Suite 1140
Washington, DC 20002-4251