(CORPORATION SOLE) ANNUAL
LIST OF SUBSCRIBER AND REGISTERED AGENT OF
NAME OF CORPORATION SOLE
FOR THE FILING PERIOD OF
The entity's duly appointed registered agent in the State of Nevada upon whom process can be served is:
A FORM TO CHANGE REGISTERED AGENT INFORMATION CAN BE FOUND ON OUR WEBSITE:
USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY
Return one file stamped copy. (If filing not accompanied by order instructions, file stamped copy will be sent to registered agent.)
**YOU MAY NOW FILE YOUR ANNUAL LIST ONLINE AT www.nvsos.gov**
IMPORTANT: Read instructions before completing and returning this form. 1. Print or type name and address, either residence or business, of subscriber or successor submitting the list. The Subscriber or Successor must sign the form. FORM WILL BE RETURNED IF UNSIGNED. 2. If there are additional subscribers, attach a list of them to this form. 3. Return the completed form with the $25.00 filing fee. A $50.00 penalty must be added for failure to file this 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. Make your check payable to the Secretary of State. Your canceled check will constitute a certificate to transact business. 5. 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. 6. Return the completed form to: Secretary of State, 202 North Carson Street, Carson City, Nevada 89701-4201, (775) 684-5708. 7. 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.
FILING FEE: $25.00 LATE PENALTY: $50.00
I declare, to the best of my knowledge under penalty of perjury, that the above mentioned entity has complied with the provisions of NRS 360.780 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.
Signature of Subscriber or Successor
Nevada Secretary of State Annual List Subscriber Revised: 7-1-08