Free Layout 1 - Rhode Island

State of Rhode Island and Providence Plantations
Office of the Secretary of State

A. Ralph Mollis, Secretary of State
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Corporations Division 148 W. River Street Providence, RI 02904-2615 401.222.3040

LIMITED LIABILITY COMPANY ANNUAL REPORT FOR THE YEAR ____________

Filing Period: September 1 - November 1 · Filing Fee: $50.00* · THIS REPORT MUST BE TYPED OR PRINTED LEGIBLY IN BLACK INK. * In accordance with R.I.G.L. 7-16-66 (d), each limited liability company failing or refusing to file its annual report within thirty (30) days after the time prescribed by law (R.I.G.L. 7-16-66 (b&c)) is subject to a penalty fee of $25.00.
1. ID No. 2. Exact name of the limited liability company

3. State of Formation

4. Brief description of the character of the business which is actually conducted in Rhode Island

5. Principal office address

City

State

Zip

6. MAILING ADDRESS OF LIMITED LIABILITY COMPANY AND NAME OR TITLE OF CONTACT PERSON:
Contact Name Contact Title

Street Address

City

State

Zip

7. NAME AND ADDRESS OF EACH MANAGER OF THE LIMITED LIABILITY COMPANY, IF APPLICABLE - DO NOT ("X" BOX FOR ATTACHMENT) FILL IN SPACES BEFORE USING ATTACHMENTS
Manager Name Manager Name

LIST MEMBERS

Street Address

Street Address

City

State

Zip

City

State

Zip

Manager Name

Manager Name

Street Address

Street Address

City

State

Zip

City

State

Zip

8. RESIDENT AGENT IN RHODE ISLAND

This information is currently of record in the Office of the Secretary of State. Changes require filing of Form 642 - R.I.G.L. 7-16-11

This report must be executed by an authorized person pursuant to R.I.G.L. 7-16-66 (b).

Under penalty of perjury, I declare and affirm that I have examined this report, including any accompanying schedules and statements, and that all statements contained herein are true and correct.
File Date ________________________________________ Check No. ________________________________________ By: ______________________________________________
FOR SECRETARY OF STATE USE ONLY

Signature of Authorized Person

Date

Print or Type Name of Authorized Person Form 632 Rev. 08/08

INSTRUCTIONS FOR FILING A LIMITED LIABILITY COMPANY ANNUAL REPORT
To avoid possible delays, please read all instructions carefully before completing the report.

________________________________________________________________________________
All sections, including the signature and date, must be completed; otherwise, the report will be returned to you. To file this report online using Visa, MasterCard, or American Express, visit www.sec.state.ri.us/corps and simply click on the "File Annual Reports Online" link. FOR IMAGING PURPOSES, THE REPORT MUST BE TYPED OR PRINTED LEGIBLY IN BLACK INK. The report must be signed and dated. It shall be executed by an authorized person of a domestic limited liability company or by a person with authority to do so under the laws of the state or other jurisdiction of organization of a foreign limited liability company. Annual Reports are to be filed annually between the first day of September and the first day of November, but in no event should they be submitted for filing more than sixty (60) days prior to the commencement of the filing period. Failure to file the report and remit the filing fee may result in revocation of the Certificate of Organization or the Certificate of Registration. In accordance with R.I.G.L. 7-16-66 (d), each limited liability company failing or refusing to file its annual report within thirty (30) days after the time prescribed by law (R.I.G.L. 7-16-66 (b&c)) is subject to a penalty fee of $25.00. In order to accurately complete this form, please log onto our corporate database at www.sec.state.ri.us/corps to view your entity summary screen or to obtain a copy of your last annual report filing.

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Section 1. List your Rhode Island entity identification number. Please include this number on your check and refer to it in any future correspondence or filings with the Corporations Division. Section 2. List the exact name of the limited liability company as it appears on the Articles of Organization or latest amendment. If the entity name has changed, an amendment must be filed with this office. Amendment to Articles of Organization forms (Domestic Limited Liability Company) or Amendment to Application for Registration forms (Foreign Limited Liability Company) can be filed online using Visa, MasterCard, or American Express, visit www.sec.state.ri.us/corps and simply click on the "File Corporations Online" link or a paper form can be obtained by selecting "Corporate Forms." Of course, we will provide a hardcopy of the form upon request by calling 401-222-3040. Section 3. List the state or country of formation. If the information is incorrect on your entity summary screen, please contact this office. Section 4. Provide a brief statement of the character of the business in which the limited liability company is engaged in this state. Section 5. Provide the address of the principal office of the limited liability company. Section 6. Provide the current mailing address and the name or title of a person to whom communications may be directed. Section 7. If applicable, provide the name(s) and address(es) of the limited liability company's manager(s). Attachments mustinclude the identification number of the Limited Liability Company. DO NOT LIST MEMBERS IN THIS SECTION. Section 8. The limited liability company's resident agent and registered office is of record in this office and can be found on the entity summary screen. If the resident agent and/or address of the resident agent has changed, a Statement of Change of address of Resident Agent/Resident Agent (Form 642) must be filed with this office. To file the Statement of Change online using Visa, MasterCard, or American Express, visit www.sec.state.ri.us/corps and simply click on the "File Corporations Online" link or a paper form can be obtained by selecting "Corporate Forms." Of course, we will provide a hardcopy of the form upon request by calling 401-222-3040.