Form Cr2e083b - Limited Liability Company Uniform Business Report (Ubr)
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1LIMITED LIABILITY COMPANY
UNIFORM BUSINESS REPORT (UBR)
DOCUMENT #
1. Entity Name
DO NOT WRITE IN THIS SPACE
2. Principal Place of Business
3. Mailing Address
Suite, Apt. #, etc.
Suite, Apt. #, etc.
DO NOT WRITE IN THIS SPACE
Applied For
City & State
City & State
4. FEI Number
Not Applicable
Zip
Country
Zip
Country
$5.00
Additional
5. Certificate of Status Desired
Fee Required
7. Name and Address of Current Registered Agent
Name
DO NOT WRITE
Street Address (P.O. Box Number is Not Acceptable)
IN THIS SPACE
City
Zip Code
FL
8. The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both, in the State of Florida. I am familiar with, and accept
the obligations of registered agent.
SIGNATURE
Signature, typed or printed name of registered agent and title if applicable.
DATE
FEE IS $50.00
Make Check Payable to Florida Department of State
DUE BY MAY 1
9.
MANAGING MEMBERS / MANAGERS
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
DO NOT WRITE
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
IN THIS SPACE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
11. I hereby certify that the information supplied with this filing does not qualify for the exemption stated in Section 119.07(3)(i), Florida Statutes. I further certify that the information
indicated on this report is true and accurate and that my signature shall have the same legal effect as if made under oath; that I am a managing member or manager of the
limited liability company or the receiver or trustee empowered to execute this report as required by Chapter 608, Florida Statutes.
SIGNATURE:
SIGNATURE AND TYPED OR PRINTED NAME OF SIGNING MANAGING MEMBER, MANAGER, OR AUTHORIZED REPRESENTATIVE
Date
Daytime Phone #
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