Form Si-100 - Statement Of Information (Domestic Nonprofit, Credit Union And Consumer Cooperative Corporations)

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State of California
Secretary of State
Statement of Information
(Domestic Nonprofit, Credit Union and Consumer Cooperative Corporations)
Filing Fee: $20.00. If this is an amendment, see instructions.
IMPORTANT – READ INSTRUCTIONS BEFORE COMPLETING THIS FORM
1. CORPORATE NAME
2. CALIFORNIA CORPORATE NUMBER
This Space for Filing Use Only
Complete Principal Office Address
(Do not abbreviate the name of the city. Item 3 cannot be a P.O. Box.)
3.
STREET ADDRESS OF PRINCIPAL OFFICE IN CALIFORNIA, IF ANY
C ITY
STATE
ZIP CODE
CA
4.
MAILING ADDRESS OF THE CORPORATION
C
ITY
STATE
ZIP CODE
5.
EMAIL ADDRESS FOR RECEIVING STATUTORY NOTIFICATIONS
Names and Complete Addresses of the Following Officers
(The corporation must list these three officers. A comparable title for the specific
officer may be added; however, the preprinted titles on this form must not be altered.)
5.
CHIEF EXECUTIVE OFFICER/
ADDRESS
C
ITY
STATE
ZIP CODE
6.
SECRETARY
ADDRESS
CITY
STATE
ZIP CODE
7.
CHIEF FINANCIAL OFFICER/
ADDRESS
C
ITY
STATE
ZIP CODE
Agent for Service of Process
If the agent is an individual, the agent must reside in California and Item 9 must be completed with a California street
address, a P.O. Box address is not acceptable. If the agent is another corporation, the agent must have on file with the California Secretary of State a
certificate pursuant to California Corporations Code section 1505 and Item 9 must be left blank.
[Note: The person designated as the corporation's agent MUST have agreed to act in that capacity prior to the designation.]
8.
NAME OF AGENT FOR SERVICE OF PROCESS
9.
STREET ADDRESS OF AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL
CITY
STATE
ZIP CODE
CA
Common Interest Developments
10.
Check here if the corporation is an association formed to manage a common interest development under the Davis-Stirling Common Interest
Development Act, (California Civil Code section 4000, et seq.) or under the Commercial and Industrial Common Interest Development Act,
(California Civil Code section 6500, et seq.). The corporation must file a Statement by Common Interest Development Association (Form SI-CID) as
required by California Civil Code sections 5405(a) and 6760(a). Please see instructions on the reverse side of this form.
11. THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT.
DATE
TYPE/PRINT NAME OF PERSON COMPLETING FORM
TITLE
SIGNATURE
SI-100 (REV 01/2014)
APPROVED BY SECRETARY OF STATE
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