Statement Of Consolidation Form - Colorado Secretary Of State Page 3
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7_______________________ ______________
(Province – if applicable)
(Country – if not US)
4. If one or more of the consolidating entities is a registrant of a trademark described in a filed document in the
records of the secretary of state, mark this box
and state below the document number of each such filed
document.
Document number:
_____________________
Document number:
_____________________
(If more than two trademarks, mark this box
and include an attachment stating the additional document numbers.)
5. Additional information may be included. If applicable, mark this box
and include an attachment
stating the additional information.
6. (Optional) Delayed effective date:
______________________
(mm/dd/yyyy)
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. Name(s) and address(es) of the
individual(s) causing the document
to be delivered for filing:
____________________ ______________ ______________ _____
(Last)
(First)
(Middle)
(Suffix)
_______________________________________________________
(Street name and number or Post Office Box information)
______________________________________________________
__________________________ ____ ____________________
(City)
(State)
(Postal/Zip Code)
_______________________ ______________
(Province – if applicable)
(Country – if not US)
(The document need not state the true name and address of more than one individual. However, if you wish to state the name and address
of any additional individuals causing the document to be delivered for filing, mark this box
and include an attachment stating the
name and address of such individuals.)
Disclaimer:
This form, and any related instructions, are not intended to provide legal, business or tax advice, and are
offered as a public service without representation or warranty. While this form 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. Questions should be addressed to the user’s
attorney.
CONSOLID
Page 3 of 3
Rev. 6/16/2005
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