ANNUAL REPORT
FILE DATE
____________________
Enter Filing Year
DOMESTIC NONPROFIT
Secretary of State Office
RECEIPT NO ___________________
500 E Capitol Ave
Please Type or Print Clearly in Ink
Clear Form
Pierre, SD 57501
FILING FEE: $10
(605)773-4845
SECRETARY OF STATE
Make check payable to
1. Corporate Name, Registered Agent Name and Address:
Search for Corporate ID, Name and Agent
Telephone # ____________________
South Dakota
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 principal officers and directors. Please place a check mark next to the name if the
principal officer serves as a director. South Dakota Law requires at least three directors.
_____________________________________________________________________________________________
President
Street Address
City
State
ZIP+4
_____________________________________________________________________________________________
Vice President
Street Address
City
State
ZIP+4
_____________________________________________________________________________________________
Secretary
Street Address
City
State
ZIP+4
_____________________________________________________________________________________________
Treasurer
Street Address
City
State
ZIP+4
_____________________________________________________________________________________________
Director
Street Address
City
State
ZIP+4
_____________________________________________________________________________________________
Director
Street Address
City
State
ZIP+4
_____________________________________________________________________________________________
Director
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.
annualreportdomesticnonprofit February 2011