Annual List Of Trustees And Resident Agent - Nevada Secretary Of State

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ANNUAL LIST OF TRUSTEES AND RESIDENT AGENT OF

FILE NUMBER

(Name of Business Trust)

FOR THE FILING PERIOD OF

The corporation's duly appointed resident agent in the State of Nevada upon whom process can be served is:

A FORM TO CHANGE RESIDENT AGENT INFORMATION CAN BE FOUND ON OUR WEBSITE: secretaryofstate.biz

Important: Read instructions before completing and returning this form.

USE BLACK INK ONLY - DO NOT HIGHLIGHT

ABOVE SPACE IS FOR OFFICE USE ONLY

Return one file stamped copy. (If filing not accompanied by order instructions, file stamped copy will be sent to resident agent.)

1. Print or type names and addresses, either residence or business, for all trustees. A Trustee must sign the form. FORM WILL BE RETURNED IF UNSIGNED

2. If there are additional trustees, attach a list of them to this form.

3. Return the completed form with the $125.00 filing fee, A $75.00 penalty must be added for failure to file this form by the deadline. An annual list received more than 90 days before its due

date shall be deemed an amended list for the previous year.

4. Make your check payable to the Secretary of State. Your canceled check will constitute a certificate to transact business.

5. Ordering Copies: If requested above, one file stamped copy will be returned at no additional charge. To receive a certified copy, enclose an additional $30.00 per certification. A copy

fee of $2.00 per page is required for each additional copy generated when ordering 2 or more file stamped or certified copies. Appropriate instructions must accompany your order.

6. Return the completed form to: Secretary of State, 202 North Carson Street, Carson City, NV 89701-4201, (775) 684-5708.

7. Form must be in the possession of the Secretary of State on or before the last day of the month in which it is due. (Postmark date is not accepted as receipt date.) Forms received

after due date will be returned for additional fees and penalties.

FILING FEE $125 00

LATE PENALTY: $75.00

TITLE(S)

NAME

TRUSTEE

ADDRESS

ZIP

CITY

TITLE(S)

NAME

TRUSTEE

ADDRESS

ZIP

CITY

TITLE(S)

NAME

TRUSTEE

ADDRESS

ZIP

CITY

TITLE(S)

NAME

TRUSTEE

ADDRESS

ZIP

CITY

TITLE(S)

NAME

TRUSTEE

ADDRESS

ZIP

CITY

I declare, to the best of my knowledge under penalty of perjury, that the above mentioned entity has complied with the provisions of NRS 360.780 and acknowledge that pursuant to

NRS 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing in the Office of the Secretary of State.

Title

Date

Signature of Trustee

Nevada Secretary of State Form Annual List BT 2007

Revised on: 01/01/07

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