Instructions For Completing Form Llc-12 - Statement Of Information Page 4
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4Secretary of State
Statement of Information
LLC-12
(Limited Liability Company)
IMPORTANT —
Read instructions
before completing this form.
Filing Fee - $20.00
Copy Fees – Face Page $1.00 & .50 for each attachment page;
Certification Fee - $5.00
This Space For Office Use Only
1. Limited Liability Company Name
2. 12-Digit Secretary of State File Number
3. State or Place of Organization (only if formed outside of California)
4. Business Addresses
a. Street Address of Principal Office - Do not list a P.O. Box
City (no abbreviations)
State
Zip Code
b. Mailing Address of LLC, if different than item 4a
City (no abbreviations)
State
Zip Code
c. Street Address of California Office, if Item 4a is not in California - Do not list a P.O. Box
City (no abbreviations)
State
Zip Code
CA
If no managers have been appointed or elected, provide the name and address of each member. At least one name and address
must be listed. If the manager/member is an individual, complete Items 5a and 5c (leave Item 5b blank). If the manager/member is an
5. Manager(s) or Member(s)
entity, complete Items 5b and 5c (leave Item 5a blank). Note: The LLC cannot serve as its own manager or member. If the LLC has
additional managers/members, enter the name(s) and addresses on Form LLC-12A
(see
instructions).
a. First Name, if an individual - Do not complete Item 5b
Middle Name
Last Name
Suffix
b. Entity Name - Do not complete Item 5a
c. Address
City (no abbreviations)
State
Zip Code
Item 6a and 6b: If the agent is an individual, the agent must reside in California and Item 6a and 6b must be completed with the
6. Agent for Service of
agent’s name and California address. Item 6c: If the agent is a California Registered Corporate Agent, a current agent registration
Process
certificate must be on file with the California Secretary of State and Item 6c must be completed (leave Item 6a-6b blank).
a. California Agent's First Name (if agent is not a corporation)
Middle Name
Last Name
Suffix
b. Street Address (if agent is not a corporation) - Do not list a P.O. Box
City (no abbreviations)
State
Zip Code
CA
c. California Registered Corporate Agent’s Name (if agent is a corporation) – Do not complete item 6a or 6b
7. Type of Business
a. Describe the type of business or services of the Limited Liability Company
8. Chief Executive Officer, if elected or appointed
a. First Name
Middle Name
Last Name
Suffix
b. Address
City (no abbreviations)
State
Zip Code
9. The Information contained herein, including any attachments, is true and correct.
_____________________
_____________________________________________________________
________________________
__________________________________
Date
Type or Print Name of Person Completing the Form
Title
Signature
Return Address (Optional)
(For communication from the Secretary of State related to this document, or if purchasing a copy of the filed document enter the name of a
person or company and the mailing address. This information will become public when filed.
SEE INSTRUCTIONS
BEFORE COMPLETING.)
Name:
Company:
Address:
City/State/Zip:
2016 California Secretary of State
LLC-12 (REV 07/2016)
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