Name
Address
8.
Name and address
of each director of
corporation
City
State
Zip
Country
If additional space is needed,
please provide attachment.
Name
Address
Leave this question blank if
the directors and officers are
the same.
City
State
Zip
Country
Name
Address
City
State
Zip
Country
9.
Federal Employer Identification Number (FEIN)
10. What is the nature and kind of business in which corporation is engaged?
11. Total number of shares of capital stock issued
12a. Does this corporation hold more than 50% equity ownership in any other business entity that is filed with the
Kansas Secretary of State?
o
o
Yes (Complete Question 12b.)
No (Skip to Question 13.)
Business Entity Name
Business Entity ID Number
12b. Name and ID number
of each business
Name and ID # should be
Business Entity Name
Business Entity ID Number
provided exactly as filed with
Kansas Secretary of State.
ID number is not Federal
Business Entity Name
Business Entity ID Number
Employer ID Number (FEIN).
13. Does this corporation own or lease land in Kansas that is suitable for use in agriculture?
This question does not apply to 1) tracts of land of fewer than 10 acres, 2) contiguous tracts of land that are fewer than 10 acres in aggregate, or 3)
state-assessed railroad operating property.
o
o
Yes (Complete Attachment AG.)
No
14. 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.
Signature of Authorized Officer
X
Name of Signer (printed or typed)
Title/Position
Phone Number
2 / 2
Please review to ensure completion.
K.S.A. 17-7503, 17-7505
Rev. 12/22/16 tc