FILE NUMBER
ANNUAL LIST OF TRUSTEES AND RESIDENT AGENT OF
_____________________________________________________________________
_____________________
(Name of Business Trust)
A ____________________________________ BUSINESS TRUST
FOR THE FILING PERIOD _________________TO________________
(State of Formation)
The Business Trust’s duly appointed resident agent in the State of Nevada
Office Use Only
upon whom process can be served is:
IF AGENT INFORMATION HAS CHANGED, PLEASE SEE ATTACHED
INSTRUCTIONS ON HOW TO OBTAIN THE APPROPRIATE FORM.
Important: Read instructions before completing and returning this form.
1. Print or type names and addresses, either residence or business, for at least one trustee. A Trustee of the company must sign the form.
FORM WILL BE
RETURNED IF UNSIGNED
2. If there are additional trustees, attach a list of them to this
form..
3. Return the completed form with the $85.00 filing fee. A $15.00 penalty must be added for failure to file this form by the last day of the anniversary month of the original registration with this office.
4. Make your check payable to the Secretary of State. Your cancelled check will constitute a certificate to transact business. If you need a receipt, return page 2 certificate and ENCLOSE A SELF- ADDRESSED
STAMPED ENVELOPE. To receive a certified copy, enclose a copy of this completed form, an additional $10.00 and appropriate instructions.
5. Return the completed form to: Secretary of State, 101 North Carson Street, Suite 3, Carson City, NV 89701-4786, (775) 684-5708.
FILING FEE: $85.00
LATE PENALTY: $15.00
NAME
TITLE(S)
TRUSTEE
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PO BOX
STREET ADDDRESS
CITY
ST
ZIP
NAME
TITLE(S)
TRUSTEE
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PO BOX
STREET ADDDRESS
CITY
ST
ZIP
NAME
TITLE(S)
TRUSTEE
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PO BOX
STREET ADDDRESS
CITY
ST
ZIP
NAME
TITLE(S)
TRUSTEE
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PO BOX
STREET ADDDRESS
CITY
ST
ZIP
NAME
TITLE(S)
TRUSTEE
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PO BOX
STREET ADDDRESS
CITY
ST
ZIP
NAME
TITLE(S)
TRUSTEE
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PO BOX
STREET ADDDRESS
CITY
ST
ZIP
I hereby certify this annual list.
X Signature of Trustee
Date
Nevada Secretary of State Form ANNUAL LIST OF BUSTRUST1999.01
Revised on: 01/11/00