Form Ec 50 - Electric Cooperative Annual Report Page 2
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22. Officers:
Director
Name
Residential address
City
State
Zip
Yes
No
Pres.
Sec.
Treas.
3. Board of Directors: (if not listed in 2)
Name
Residential address
City
State
Zip
4. The number of memberships issued:
.
5. The change or changes, if any, in the particulars made since the last annual report:
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed on the ________ of ___________ , _____________ .
Day
Month
Year
Name (printed or typed)
Authorized signature
Title/position
Instructions
1. The annual franchise tax of $40 must accompany this report.
2. Please be sure to enclose a check made payable to the secretary of state with the annual report. Please do not
send cash.
Notice: There is a $25 service fee for all returned checks.
Rev. 8/13/03 amc
K.S.A. 17-4634
2/2
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