Change Of Structure Application - New Mexico Regulation And Licensing Department Page 3

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CHANGE OF STRUCTURE/CONVERSION CHECKLIST –No Hearing/Posting
***Same members converting from Corporation to LLC or from LLC to a Corporation or Sole Proprietor to LLC/Corp.***
Date Received: ____________________ License No.: ________________Type: _______________________ Expires: __________________
Applicant Name: ________________________________________
___________________________________________________
Licensee: ________________________________________________________________________________________________
D/B/A Name: _____________________________________________________________________________________________
Location: ________________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________________
Is License Suspended? ___Yes ___No Is it being leased? ___Yes ___No Lease Expires: ______________
REQUIREMENTS:
Tax Hold? ___Yes ___No
Any Citations pending? ___Yes ___No
: _________________________________________________________________________________________________
CHANGE MADE TO
_________________________________________________________________________________________________________________
P
1
&
? ___Yes ___No Application fee submitted? ___Yes ___No Amount paid $_______________
AGE
COMPLETED
SUBMITTED
Tax Registration Certificate in the name of Applicant? ___Yes ___No
Comment:___________________________________
Conveyance (Bill of Sale, Assignment, etc.) submitted? ___Yes ___No Comment: __________________________________
?
P
3A L
L
C
P
__Yes ____No Comment:_______________________________________
AGE
IMITED
IABILITY
OMPANY
AGE
Certificate of Organization? ___Yes ___No Articles of Organization? ___Yes ___No Operating Agreement? ___Yes ___No
Certificate of Registration (for Out-of-State LLC)? ____Yes ____No Comment: ______________________________________
P
3B C
? ___Yes ____No Comment:________________________________________________________
AGE
ORPORATION
Certificate of Incorporation? ____Yes ____No
Articles of Incorporation? ____Yes ____No
Certificate of Good Standing? ____Yes ____No Comment:_____________________________________________________
Certificate of Authority (for Out-of-State Corporation)? ____Yes ____No Comment: _______________________________
P
3C P
? ____Yes ____No Comment: ________________________________________________________
AGE
ARTNERSHIP
Is the Applicant a ____General Partnership or ____Limited Partnership? Comment:_________________________________
Fully executed Partnership Agreement submitted? ___Yes ___No Partnership registered with the NMSOS? ___Yes ___No
Comment:_____________________________________________________________________________________________
P
5 R
A
, for Corporation, LLC, Partnership or Trust? ____Yes ____No
$50.00 Fee paid? ____Yes ____No
AGE
ESIDENT
GENT
Name: __________________________________ Permit # ___________________________ Expires: ___________________
Comment: _____________________________________________________________________________________________
,
P
6 – P
D
A
for each person requiring disclosure
____Yes ____No
?
AGE
ERSONAL
ATA
FFIDAVIT
Comment:____________________________________________________________________________________________
%
Title | Name
SS#
FPs Submitted / Cleared On:
Permit # / Expires
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
Revised 5/16

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