Form Lc 50 - Limited Liability Company Annual Report Page 2
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28. I declare under penalty of perjury pursuant to the laws of the state of Kansas that the foregoing is true and correct
and that I have remitted the required fee.
Do not leave blank.
________________________________________________________ ________________________________________________________
Signature of member
Date (month, day, year)
________________________________________________________
Name of signer (printed or typed)
________________________________________________________
Phone number
Page 2 of 2
K.S.A . 17-76,139
Rev. 6/01/10 nr
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