Statement Curing Delinquency (Page 2 of 2) in pdf

Mailing address

______________________________________________________

(leave blank if same as street address)

(Street number and name or Post Office Box information)

______________________________________________________

__________________________ ____ ____________________

(City)

(State)

(Postal/Zip Code)

_______________________ ______________.

(Province – if applicable)

(Country – if not US)

(If the following statement applies, adopt the statement by marking the box.)

The mailing address in the records of the Secretary of State is no longer different than the street

address and is no longer required.

(If the following statement applies, adopt the statement by marking the box and include an attachment.)

This document contains additional information as provided by law.

(Caution: Leave blank if the document does not have a delayed effective date. Stating a delayed effective date has

significant legal consequences. Read instructions before entering a date.)

(If the following statement applies, adopt the statement by entering a date and, if applicable, time using the required format.)

The delayed effective date and, if applicable, time of this document is/are __________________________.

(mm/dd/yyyy hour:minute am/pm)

Notice:

Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or

acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the

individual's act and deed, or that the individual in good faith believes the document is the act and deed of the

person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity

with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic

statutes, and that the individual in good faith believes the facts stated in the document are true and the

document complies with the requirements of that Part, the constituent documents, and the organic statutes.

This perjury notice applies to each individual who causes this document to be delivered to the secretary of

state, whether or not such individual is named in the document as one who has caused it to be delivered.

7. The true name and mailing address of the individual causing the document to be delivered for filing are

____________________ ______________ ______________ _____

(Last)

(First)

(Middle)

(Suffix)

______________________________________________________

(Street number and name or Post Office Box information)

______________________________________________________

__________________________

____________________

(City)

(State)

(Postal/Zip Code)

_______________________ ______________.

(Province – if applicable)

(Country – if not US)

(If the following statement applies, adopt the statement by marking the box and include an attachment.)

This document contains the true name and mailing address of one or more additional individuals causing

the document to be delivered for filing.

Disclaimer:

This form/cover sheet, and any related instructions, are not intended to provide legal, business or tax advice,

and are furnished without representation or warranty. While this form/cover sheet is believed to satisfy

minimum legal requirements as of its revision date, compliance with applicable law, as the same may be

amended from time to time, remains the responsibility of the user of this form/cover sheet. Questions should

be addressed to the user’s legal, business or tax advisor(s).

CURE_DLQ

Page 2 of 2

Rev. 8/08/2012

Statement Curing Delinquency Page 2

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