Form 632 - Limited Liability Company Annual Report For The Year - Secretary Of State, State Of Rhode Island And Providence Plantations

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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Office of the Secretary of State - Division of Business Services
148 W. River Street, Providence, Rhode Island 02904-2615
Phone: (401) 222-3040 ~ Email: corporations@sos.ri.gov ~ Website:
LIMITED LIABILITY COMPANY ANNUAL REPORT FOR THE YEAR ___________
Filing Period: September 1 - November 1 • This report must be typed or printed legibly.
Filing Fee: $50.00 • FAILURE TO FILE THIS REPORT BY DECEMBER 1 WILL RESULT IN A $25.00 PENALTY FEE.
1. Entity ID No.
2. Exact name of the limited liability company
3. State of Formation
4. Brief description of the character of business conducted in Rhode Island
5. Principal office address
City
State
Zip
6. MAILING ADDRESS OF LIMITED LIABILITY COMPANY AND NAME OR TITLE OF CONTACT PERSON:
Contact Name
Contact Title
Street Address
City
State
Zip
7. LIST ALL MANAGERS (NAMES AND ADDRESSES) OF THE LIMITED LIABILITY COMPANY, IF APPLICABLE - DO NOT LIST MEMBERS
(“X” BOX FOR ATTACHMENT)
Manager Name
Manager Name
Street Address
Street Address
City
State
Zip
City
State
Zip
Manager Name
Manager Name
Street Address
Street Address
City
State
Zip
City
State
Zip
8. RESIDENT AGENT IN RHODE ISLAND
This information is currently of record in the Office of the Secretary of State. Changes require filing Form 642.
Under penalty of perjury, I declare and affirm that I have examined
this report, including any accompanying schedules and statements,
File Date ________________________
and that all statements contained herein are true and correct.
Check No _______________________
__________________________________________________________
Signature of Authorized Person
Date
By: ____________________________
__________________________________________________________
FOR SECRETARY OF STATE USE ONLY
Print or Type Name of Authorized Person
Form No. 632
Revised: 01/2012

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