Form C And S 2500w - Michigan Domestic Profit Corporation Information Update

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MICHIGAN DOMESTIC PROFIT CORPORATION INFORMATION UPDATE

YEAR ____________

1. Corporate Name

2. IDENTIFICATION NUMBER

3. Resident Agent

4a. Registered Office Address in Michigan - NO. STREET, CITY, ZIP (may not be a P.O. Box)

4b. Mailing Address of Registered Office, if different than address in Item 4a. (may be a P.O. Box)

5. Describe the general nature and kind of business in which the corporation is engaged:

NAME

BUSINESS OR RESIDENCE ADDRESS

President (Required)

Secretary (Required)

Treasurer (Required)

Vice President

Director

7. The filing fee is $15.00. Please make your check or money order payable to the State of Michigan. This report must be filed on or before May

15, 2001. Return this signed report with fee to:

Michigan Department of Consumer and Industry Services

Bureau of Commercial Services

Corporation Division

P.O. Box 30702

Lansing, MI 48909-8202

(517) 241-6460

Signature of an authorized officer or agent

Title

Date

Phone (Optional)

If more space is needed, additional pages may be included. Do not staple any items to the report.

This report is required by Section 911, Act 284, Public Acts of 1972, as amended. Failure to file this report may result in the dissolution of the corporation.

Professional Service Corporations must include a C&S 314 - List of Shareholders.

C&S 2500w (Rev. 10/00)