Form Fbar - Annual Report Foreign
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1SECRETARY OF STATE
FILE DATE ________________
ANNUAL REPORT
STATE CAPITOL
RECEIPT NO. ______________
500 E. CAPITOL AVE.
FOREIGN
PLEASE TYPE OR USE BLACK INK
PIERRE, S.D. 57501
Clear Form
(605)773-4845
FILING FEE: $30 MAKE CHECK PAYABLE TO SECRETARY OF STATE
Fax (605)773-4550
ADDITIONAL PENALTY FEE OF $50 APPLIES TO ALL LATE FILINGS
Information
1. Corporate Name and Mailing Address, including Zip + 4:
Telephone # __________________________
FAX # ______________________________
Federal Taxpayer ID # __________________
FILING DATE: Due during the month the
Certificate of Authority was issued, and
delinquent after the last day of the following
month.
* * * * ATTENTION - FILING INSTRUCTIONS * * * *
If ALL of the information is identical as set forth in the prior report, you may check the box below and sign the report in the presence of a notary public.
Any change requires full completion of the form.
ALL OF THE INFORMATION REQUIRED ON THE ANNUAL REPORT IS IDENTICAL AS SET FORTH IN THE PRIOR REPORT.
2. It is incorporated under the laws of __________________________________ and the address of its principal office or registered office in the state
of incorporation is _________________________________________________________________________________ Zip + 4 _______________
3. The address of its registered office in South Dakota is ___________________________________________________________________________
________________________________________________________________________________________________ Zip + 4 _______________
and the name of its registered agent at such address is ___________________________________________________________________________
4. The character of the business in which it is actually engaged in South Dakota _________________________________________________________
_____________________________________________________________________________________________________________
5. The names and addresses of its directors and officers:
NAME
OFFICE
STREET ADDRESS
CITY
STATE
ZIP
__________________________________________ Director ______________________________________________________________________
__________________________________________ Director ______________________________________________________________________
__________________________________________ President _____________________________________________________________________
__________________________________________ Vice President _________________________________________________________________
__________________________________________ Secretary _____________________________________________________________________
__________________________________________ Treasurer _____________________________________________________________________
6. The aggregate number of shares which it has authority to issue, itemized by classes, par value of shares, shares without par value, and
series, if any, within a class:
NUMBER OF SHARES CAN ISSUE
CLASS
SERIES
PAR VALUE OR STATE THAT SHARES ARE NO PAR VALUE
7. NUMBER OF SHARES ISSUED
CLASS
SERIES
8. The amount of its stated capital is $ ______________________________.
The report must be signed by the chairman of the board of directors, or its president, or any other officer in the presence of a notary public.
_______________________.
________________________________________________
Dated
(Signature)
___________________________
_______________________________________________
STATE OF
_________________________
COUNTY OF
(Title)
On this the __________day of ________________________, 20______, before me, _____________________________________________________
personally appeared _______________________________________________________________________________, known to me, or proved to me,
to be the ____________________________________________________________ of the corporation that is described in and that executed the within
instrument and acknowledged to me that such corporation executed the same.
____________________________________
_______________________________________________
My Commission Expires
(Notary Public)
(Notarial Seal)
FBAR.PDF
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