Free RETURN TO - South Dakota

Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605)773-4845

ANNUAL REPORT
DOMESTIC
Please Type or Print Clearly in Ink

FILE DATE

____________________

RECEIPT NO ___________________

FILING FEE: $50 Make check payable to SECRETARY OF STATE
1. Corporate ID and Name:

Clear Form
HELP
Telephone # ____________________ FAX # _______________________

Search for Corporate ID, Name and Agent

FILING DATE: Due during the month the Certificate of Incorporation was issued, and delinquent after the last day of the following month.

2. The address of the principal executive office in or out of the State of South Dakota. ______________________________________________________________________________________________
Street Address City State ZIP+4

______________________________________________________________________________________________
Mailing Address (Optional) City State ZIP+4

3. The name of the South Dakota Registered Agent _______________________________________________________ ______________________________________________________________________________________________
Street Address (Required to be a South Dakota Address) City State ZIP+4

______________________________________________________________________________________________
Mailing Address (Optional ­ Required to be a South Dakota Address) City State ZIP+4

4. The names and business addresses of its principal officers and directors. Please place a check mark next to the name if the principal officer serves as a director. South Dakota Law requires at least one director. _____________________________________________________________________________________________
President Street Address City State ZIP+4

_____________________________________________________________________________________________
Vice President Street Address City State ZIP+4

_____________________________________________________________________________________________
Secretary Street Address City State ZIP+4

_____________________________________________________________________________________________
Treasurer Street Address City State ZIP+4

_____________________________________________________________________________________________
Director Street Address City State ZIP+4

_____________________________________________________________________________________________
Director Street Address City State ZIP+4

Dated ____________________________

______________________________________________
(Signature of an authorized officer)

______________________________________________
(Printed Name)

______________________________________________
(Title)

domesticannualreport July 2009