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Statement Of Qualification Of Foreign Limited Liability Partnership - Arkansas Secretary Of State Page 2

Arkansas Secretary of State

ark

artin

State Capitol • Little Rock, Arkansas 72201-1094

501-682-3409 •

Business & Commercial Services, 250 Victory Building, 1401 W. Capitol, Little Rock

Annual Report – Contact Information

LIMITED LIABILITY PARTNERSHIP

PLEASE TYPE OR PRINT CLEARLY IN INK

JURISDICTION (SELECT ONE)

□

DOMESTIC

FOREIGN

In order for this entity to receive its annual reporting form, please complete and file with the Office of the Secretary of

State at the time of filing.

_____________________________________________________

__________________________________________________

Entity name as used in Arkansas

Contact Person

_____________________________________________________

__________________________________________________

Street Address or Post Office Box Number

City, State & Zip

_____________________________________________________

__________________________________________________

Telephone Number

E-mail Address

NOTE: Annual Reports will be due on or before April 1

the year following filing or qualification in this state.

I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class

C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days.

Executed this ___________ day of _____________, __________________.

_____________________________________________________

__________________________________________________

Signature

Authorized Officer (Type or Print)

Rev. 03/08

Statement Of Qualification Of Foreign Limited Liability Partnership - Arkansas Secretary Of State Page 2