Foreign Registration Statement

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State of Utah

Department of Commerce

Division of Corporations & Commercial Code

Foreign Registration Statement (Foreign Series Limited Liability Company)

Clear Form

Instructions

Important: Read instructions before completing form

Non-Refundable Processing Fee: $70.00

1. Exact Name of Foreign Limited Liability Company

2. Jurisdiction of Formation:

3. Principal office address:

____________________________________________________________________________________________________

Address

City

State

Zip

4. The debts, liabilities, and obligations incurred, contracted for, or otherwise existing with respect to this particular series, if any, are enforceable

against the assets of such series only, and not against the assets of the foreign limited liability company generally or any other series.

Yes

5. The name of the Registered Agent (Individual or Business Entity or Commercial Registered Agent):

__________________________________________________________________________________________

The address must be listed if you have a non-commercial registered agent. See instructions for further details.

_____________________________________________________________

Address of the Registered Agent:

Utah Street Address Required, PO Boxes can be listed after the Street Address

City:

State UT

Zip:

6. The Limited Liability Company shall use as its name in Utah:

______________________________________________________________________________

Must be the same as number (1) unless the name is not available or permitted in Utah

7. Purpose of the Limited Liability Company:

(optional)

8. Managers/Members of the Limited Liability Company:

(optional)

Position

Name

Address

City

State

Zip

MANAGER:

MEMBER:

Under penalties of perjury, I declare that this application for authority to transact business has been examined by me and is, to the best of my knowledge and belief,

true, correct and complete.

Sign here after the form is printed

Authorized Signature:

Name & Title:

Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you may use

the business entity physical address rather than the residential or private address of any individual affiliated with the entity.

Optional Inclusion of Ownership Information: This information is not required.

Is this a female owned business?

Yes

Select/Type the race of the owner here

Is this a minority owned business?

Yes

If yes, please specify:

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Mailing/Faxing Information: