Form Sdcl 59-11-24 - Annual Report Domestic Business Corporation - South Dakota Page 2
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25. The names and business addresses of its principal officers and directors (governors). If, pursuant to SDCL 47-1A-
732(1), the board of directors has been eliminated, list the names of the shareholders.
Shareholder/Governor
Actual Street Address
City
State
ZIP+4
Shareholder/Governor
Actual Street Address
City
State
ZIP+4
Shareholder/Governor
Actual Street Address
City
State
ZIP+4
6. Beneficial Interest
(optional)
Owner
Description of Ownership
Percentage/Value
Owner
Description of Ownership
Percentage/Value
No person may execute this report knowing it is false in any material respect. Any violation may be subject to a civil and/or
criminal penalty (SDCL 47-1A-129; 22-39-36).
Dated
Signature of an authorized person
Email
(Optional)
Printed Name
Page 2 of 2
Annualreportdomestic June 2016
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