Initial List/annual List And State Business License Application Form - Nevada Secretary Of State

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INITIAL/ANNUAL LIST OF MANAGERS OR MANAGING MEMBERS AND STATE

BUSINESS LICENSE APPLICATION OF:

ENTITY NUMBER

NAME OF LIMITED-LIABILITY COMPANY

*100401*

FOR THE FILING PERIOD OF

*100401*

USE BLACK INK ONLY - DO NOT HIGHLIGHT

**YOU MAY FILE THIS FORM ONLINE AT

Return one file stamped copy.

(If filing not accompanied by order instructions,

file stamped copy will be sent to registered agent.)

IMPORTANT: Read instructions before completing and returning this form.

1. Print or type names and addresses, either residence or business, for all manager or managing

members. A Manager, or if none, a Managing Member of the LLC must sign the form. FORM WILL

BE RETURNED IF UNSIGNED.

2. If there are additional managers or managing members, attach a list of them to this form.

3. Return completed form with the fee of $125.00. A $75.00 penalty must be added for failure to file this

ABOVE SPACE IS FOR OFFICE USE ONLY

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. State business license fee is $200.00. Effective 2/1/2010, $100.00 must be added for failure to file form by deadline.

5. Make your check payable to the Secretary of State.

6. 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.

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

8. 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. Failure to include annual list and business license fees will result in rejection of filing.

ANNUAL LIST FILING FEE: $125.00

LATE PENALTY: $75.00 (if filing late)

BUSINESS LICENSE FEE: $200.00

LATE PENALTY: $100.00 (if filing late)

CHECK ONLY IF APPLICABLE AND ENTER EXEMPTION CODE IN BOX BELOW

NRS 76.020 Exemption Codes

001 - Governmental Entity

Pursuant to NRS Chapter 76, this entity is exempt from the business license fee.

Exemption code:

005 - Motion Picture Company

006 - NRS 680B.020 Insurance Co.

NOTE: If claiming an exemption, a notarized Declaration of Eligibility form must be attached. Failure to

attach the Declaration of Eligibility form will result in rejection, which could result in late fees.

NAME

MANAGER OR MANAGING MEMBER

ADDRESS

CITY

STATE

ZIP CODE

NAME

MANAGER OR MANAGING MEMBER

ADDRESS

CITY

STATE

ZIP CODE

NAME

MANAGER OR MANAGING MEMBER

ADDRESS

CITY

STATE

ZIP CODE

NAME

MANAGER OR MANAGING MEMBER

ADDRESS

CITY

STATE

ZIP CODE

None of the managers or managing members identified in the list of managers and managing members has been identified with the fraudulent intent of concealing

the identity of any person or persons exercising the power or authority of a manager or managing member in furtherance of any unlawful conduct.

I declare, to the best of my knowledge under penalty of perjury, that the information contained herein is correct 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 Manager, Managing Member or

Other Authorized Signature

Nevada Secretary of State List ManorMem

Revised: 8-8-13

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