ANNUAL REPORT
FILE DATE
____________________
Enter Filing Year
FOREIGN L.L.C.
Secretary of State Office
RECEIPT NO ___________________
500 E Capitol Ave
Please Type or Print Clearly in Ink
Pierre, SD 57501
Clear Form
FILING FEE: $50
(605)773-4845
SECRETARY OF STATE
Make check payable to
1. L.L.C. ID and Name:
Search for Corporate ID, Name and Agent
Telephone # ____________________
2. The jurisdiction under whose law it is formed ___________________________________________________________
3. The address of the principal executive office (business address).
______________________________________________________________________________________________
Street Address
City
State
ZIP+4
______________________________________________________________________________________________
Mailing Address
City
State
ZIP+4
______________________________________________________________________________________________________________________
Email Address
4. The name of the South Dakota Registered Agent _______________________________________________________
______________________________________________________________________________________________
Street Address or Rural Route Box Number in This State and
City
State
ZIP+4
______________________________________________________________________________________________
Mailing Address in This State, if Different from Street Address
City
State
ZIP+4
______________________________________________________________________________________________________________________
Email Address
5. The names and addresses of its managers. If the L.L.C. is member-managed the names and addresses of the
members need not be set forth.
______________________________________________________________________________________________
Manager
Street Address
City
State
ZIP+4
______________________________________________________________________________________________
Manager
Street Address
City
State
ZIP+4
______________________________________________________________________________________________
Manager
Street Address
City
State
ZIP+4
No person may execute this report knowing it is false in any material respect. Any violation is subject to a civil penalty.
Dated ____________________________ ________
______________________________________________
(Signature of an Authorized Person)
Email _____________________________________
______________________________________________
(Printed Name)
*By signing this form you agree to have both the fee and the form processed electronically.
annualreportforeignllc February 2011