Nonprofit Report - South Dakota Secretary Of State

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SECRETARY OF STATE

FILE DATE ________________

NONPROFIT REPORT

STATE CAPITOL

RECEIPT NO. ______________

500 E. CAPITOL AVE.

PLEASE TYPE OR USE BLACK INK

Clear Form

PIERRE, S.D. 57501

(605)773-4845

FILING FEE: $10 MAKE CHECK PAYABLE TO SECRETARY OF STATE

Fax (605)773-4550

ADDITIONAL PENALTY FEE OF $25 APPLIES TO ALL LATE FILINGS

1. Corporate Name, Registered Agent and Registered Address:

Day Time Phone #______________________

Federal Identification #__________________

FILING DATE: Due during the month the

Certificate of Incorporation was issued, and

delinquent after the last day of the following

month.

IF THE REGISTERED AGENT (CONTACT PERSON) AND/OR THE REGISTERED OFFICE ADDRESS HAS CHANGED

IN NUMBER ONE, THE STATEMENT OF CHANGE FORM IS REQUIRED TO BE COMPLETED.

2. The nature of the affairs which the corporation is conducting in South Dakota is ______________________________________________________

_____________________________________________________________________________________________________________

3. A. The amount of property which the corporation is authorized to hold is unlimited or as set forth in the articles of incorporation.

B. The amount of property presently held by the corporation is $ ________________________________________________________________ *

* Property should include all real or personal property, or any interest therein, wherever situated.

4. The names and addresses of the corporation officers:

NAME

OFFICE

STREET ADDRESS

CITY

STATE

ZIP

__________________________________________ President _____________________________________________________________________

__________________________________________ Vice President _________________________________________________________________

__________________________________________ Secretary _____________________________________________________________________

__________________________________________ Treasurer _____________________________________________________________________

5. The names and addresses of directors (State law requires a minimum of three). If the directors and officers are the same individuals, please check the

box next to the person's name above. Attach an additional sheet if more space is needed to list directors.

NAME

OFFICE

STREET ADDRESS

CITY

STATE

ZIP

__________________________________________ Director ______________________________________________________________________

The report must be signed by the chairman of the board of directors, or its president, or any other officer.

________________________.

_______________________________________________

Dated