(See §34.10 of this chapter.)

(Submit an original and four copies.)

[Name of respondent]

Report of Securities Issued

Description of security....................................

Open Table
Description Amount
1. Face value or principal amount
2. Plus premium or less discount
3. Gross proceeds
4. Underwriter's spread or commission
5. Securities and Exchange Commission registration fee
6. State mortgage registration tax
7. State commission fee
8. Fee for recording indenture
9. United States document tax
10. Printing and engraving expenses
11. Trustee's charges
12. Counsel fees
13. Accountant's fees
14. Cost of listing
15. Miscellaneous expenses of issue
(Describe large items)
16.         Total deductions
17.         Net amount realized

[Order 141, 12 FR 8591, Dec. 19, 1947, as amended by Order 182, 46 FR 50517, Oct. 14, 1981]


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