Fillable Amendment Or Correction To Biennial Report

Amendment Or Correction To Biennial Report - 2013 Page 2

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INSTRUCTIONS FOR COMPLETING

AMENDMENT OR CORRECTION TO BIENNIAL REPORT FORM

1. Name--Please state the exact name of the Foreign Corporation or Domestic Corporation, as it appears

in the Articles of Incorporation or Certificate of Authority filed with the Nebraska Secretary of State.

2. Type of Biennial Report being amended or corrected: Select the check box which corresponds to the

type of Biennial Report this Amendment or Correction refers to either Foreign or Domestic Corporation.

3. Reporting period-The amending party is required to submit a separate Amendment or Correction form

for each prior biennial report being corrected or amended and pay applicable fee for each form to be filed

(see below).

4. Officer or Director changes or additions: For a change or addition to an Officer, you must provide

officer’s name and the title of the office (example: President) and complete address. For Director changes

or additions, provide the name of the director and complete address.

5. Address of Principal Office: Please provide the complete address if amending or correcting the

Principal Office.

6. Correction to Name of State or Jurisdiction: Please provide the name of the state or jurisdiction under

whose laws it was originally filed.

7. Nature of Business: State the amended or corrected nature of business conducted in Nebraska.

8. Location of Property Owned or Used in Nebraska: State the amended or corrected location of property

owned or used in Nebraska.

9. Actual Value of Real Estate and Personal Property in Nebraska (if Foreign Corporation) OR Amount

of Paid Up Capital Stock (if Domestic Corporation): Select the applicable check box for the type of

corporation. Provide the original dollar amount reported on the Biennial Report being amended or

corrected and the corrected dollar amount. (Enclose additional occupation tax due for reporting period or

if refund is due, contact Secretary of State for refund form to submit with this Amendment or Correction.

Attach explanation of increase or decrease in Actual Value of Real Estate or Personal Property (if Foreign

Corporation) or Amount of Paid Up Capital Stock (if Domestic Corporation).

10. Signature of person completing the Amendment or Correction to Biennial Report

Filing fee is $30.00 (plus $5.00 per page for any additional pages)

Make check payable to: Secretary of State.

Amendment Or Correction To Biennial Report - 2013 Page 2

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