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SECRETARY OF STATE

FILE DATE ________________

ANNUAL REPORT

STATE CAPITOL

RECEIPT NO. ______________

DOMESTIC

500 E. CAPITOL AVE.

PLEASE TYPE OR USE BLACK INK

PIERRE, S.D. 57501

(605)773-4845

FILING FEE: $25 MAKE CHECK PAYABLE TO SECRETARY OF STATE

Fax (605)773-4550

ADDITIONAL PENALTY FEE OF $50 APPLIES TO ALL LATE FILINGS

1. Corporate Name, Registered Agent and Registered Address:

Telephone # __________________________

FAX # ______________________________

Federal Taxpayer ID # __________________

FILING DATE: Due during the month the

Certificate of Incorporation was issued, and

delinquent after the last day of the following

month.

* * * * ATTENTION - FILING INSTRUCTIONS * * * *

If ALL of the information, including the registered agent and address listed in number one 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. To report a change in the registered agent and/or office, both sides of this form must be

fully completed. Any change requires full completion of the front side of this form.

ALL OF THE INFORMATION REQUIRED ON THE ANNUAL REPORT IS IDENTICAL AS SET FORTH IN THE PRIOR REPORT.

2. The character of the business in which it is actually engaged in South Dakota ________________________________________________________

_____________________________________________________________________________________________________________

3. The names and addresses of its directors and officers:

NAME

OFFICE

STREET ADDRESS

CITY

STATE

ZIP

__________________________________________ President _____________________________________________________________________

__________________________________________ Vice President _________________________________________________________________

__________________________________________ Secretary _____________________________________________________________________

__________________________________________ Treasurer _____________________________________________________________________

SD law requires at least one director.

Do the above listed officers serve also as directors? YES _____ NO _____ If no, list directors below.

__________________________________________ Director ______________________________________________________________________

4. 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 (authorized)

CLASS

SERIES

PAR VALUE OR STATE THAT SHARES ARE NO PAR VALUE

5. NUMBER OF SHARES ACTUALLY ISSUED

CLASS

SERIES

6. The amount of its stated capital is $ ______________________________. (Money received for issued shares)

The report must be signed by the chairman of the board of directors, 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)

dbar.pdf

Annual Report Domestic Form/statement Of Change Of Registered Office, Or Registered Agent, Or Both - South Dakota Secretary Of State

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