Unofficial Consolidation: Form 72-503F Report of Distributions Outside Canada

Unofficial Consolidation: Form 72-503F Report of Distributions Outside Canada

Forms

Ontario Securities Commission

Form 72-503F

Unofficial consolidation current to 2018-10-05

This document is not an official statement of law or policy and should be used for reference purposes only.

Form 72-503F
REPORT OF DISTRIBUTIONS OUTSIDE CANADA

Instructions:

  1. An issuer that is required to complete this Form must do so through the online e-form available at http://www.osc.gov.on.ca.
  2. Security codes: Wherever this form requires disclosure of the type of security, use the following security codes:

Security code

Security type

BND

Bonds

CER

Certificates (including pass-through certificates, trust certificates)

CMS

Common shares

CVD

Convertible debentures

CVN

Convertible notes

CVP

Convertible preferred shares

DCT

Digital coins or tokens

DEB

Debentures

DRS

Depository receipts (such as American or Global depository receipts/shares)

FTS

Flow-through shares

FTU

Flow-through units

LPU

Limited partnership units and limited partnership interests (including capital commitments)

MTG

Mortgages (other than syndicated mortgages)

NOT

Notes (include all types of notes except convertible notes)

OPT

Options

PRS

Preferred shares

RTS

Rights

SMG

Syndicated mortgages

SUB

Subscription receipts

UBS

Units of bundled securities (such as a unit consisting of a common share and a warrant)

UNT

Units (exclude units of bundled securities, include trust units and mutual fund units)

WNT

Warrants (including special warrants)

OTH

Other securities not included above (if selected, provide details of security type in Item 7d)

Distributions by more than one issuer of a single security: If two or more issuers distributed a single security, provide the full legal name(s) of the co-issuer(s) in section 1c) other than the issuer named in section 1a).

  1. Full name, address and telephone number of the Issuer.

a)           Full name of issuer

 

 

 

b)           Head office address

 

 

 

 

 

Street address

 

Province/State

 

 

 

 

 

 

 

Municipality

 

Postal code/Zip code

 

 

 

 

 

 

 

Country

 

Telephone number

 

 

 

 

 

 

 

 

c)           Full legal name(s) of co-issuer(s) (if applicable)

 

 

 

  1. Type of security, the aggregate number or amount distributed and the aggregate purchase price.

Types of securities distributed

Provide the following information for all distributions of securities relying on an exemption in section 2.3 or 2.4 of the Rule on a per security basis. Refer to section 2 of the Instructions for how to indicate the security code. If providing the CUSIP number, indicate the full 9-digit CUSIP number assigned to the security being distributed.

 

 

 

 

 

 

 

Canadian $

 

 

Security code

CUSIP
number
(if applicable)

Description of security

Number of securities

Single or lowest price

Highest price

Total amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Details of rights and convertible/exchangeable securities

If any rights (e.g. warrants, options) were distributed, provide the exercise price and expiry date for each right. If any convertible/exchangeable securities were distributed, provide the conversion ratio and describe any other terms for each convertible/exchangeable security.

Convertible/

exchangeable security code

Underlying Security code

Exercise price (Canadian $)

Expiry date (YYYY-MM-DD)

Conversion ratio

Describe other terms (if applicable)

Lowest

Highest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Date of distribution(s).

Distribution date

State the distribution start and end dates. If the report is being filed for securities distributed on only one distribution date, provide the distribution date as both the start and end dates. If the report is being filed for securities distributed on a continuous basis, include the start and end dates for the distribution period covered by the report.

 

 

 

Start date

 

 

 

 

End date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YYYY

MM

DD

 

 

YYYY

MM

DD

 

  1. State the name and address of any person acting as dealer or underwriter (including an underwriter that is acting as agent) in connection with the distribution(s) of the securities.

Dealer and underwriter information

 

Full legal name

 

 

 

Street address

 

 

 

 

 

 

 

Municipality

 

Province/State

 

 

 

 

 

 

 

Country

 

Postal code/Zip code

 

 

 

 

 

 

 

Telephone number

 

Website

 

(if applicable)

 

 

 

 

 

           
  1. Certification

Certification

Provide the following certification and business contact information of an officer, director or agent of the issuer. If the issuer is not a company, an individual who performs functions similar to that of a director or officer may certify the report. For example, if the issuer is a trust, the report may be certified by the issuer's trustee. If the issuer is an investment fund, a director or officer of the investment fund manager (or, if the investment fund manager is not a company, an individual who performs similar functions) may certify the report if the director or officer has been authorized to do so by the investment fund.

The certification may be delegated, but only to an agent that has been authorized by an officer or director of the issuer to prepare and certify the report on behalf of the issuer. If the report is being certified by an agent on behalf of the issuer, provide the applicable information for the agent in the boxes below.

The signature on the report must be in typed form rather than handwritten form. The report may include an electronic signature provided the name of the signatory is also in typed form.

Securities legislation requires an issuer that makes a distribution of securities under certain prospectus exemptions to file a completed report of exempt distribution.

By completing the information below, I certify, on behalf of the issuer/investment fund manager, to the securities regulatory authority or regulator, as applicable, that I have reviewed this report and to my knowledge, having exercised reasonable diligence, the information provided in this report is true and, to the extent required, complete.

Name of issuer/investment fund manager/agent

 

 

 

Full legal name

 

 

 

 

 

Family name

First given name

Secondary given names

 

Title

 

 

 

Telephone number

 

Email address

 

 

 

Signature

 

Date

 

 

 

 

 

 

 

YYYY

MM

DD