Free Form - Nevada

ANNUAL LIST OF MANAGERS OR MANAGING MEMBERS AND REGISTERED AGENT OF
NAME OF LIMITED-LIABILITY COMPANY FOR THE FILING PERIOD OF TO

FILE NUMBER

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:

www.nvsos.gov
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 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 the completed form with the $125.00 filing fee. A $75.00 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: $125.00 NAME LATE PENALTY: $75.00 (DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) MANAGER ADDRESS CITY MANAGING MEMBER STATE ZIP CODE

NAME

(DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) MANAGER MANAGING MEMBER STATE ZIP CODE

ADDRESS

CITY

NAME

(DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) MANAGER MANAGING MEMBER STATE ZIP CODE

ADDRESS

CITY

NAME

(DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) MANAGER MANAGING MEMBER STATE ZIP CODE

ADDRESS

CITY

NAME

(DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) MANAGER MANAGING MEMBER STATE ZIP CODE

ADDRESS

CITY

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.

X
Signature of Manager or Managing Member Reset

Title

Date

Nevada Secretary of State Annual List ManorMem Revised: 7-1-08