DOMESTIC PROFIT CORPORATION RETURN TO: NM PUBLIC REGULATION COMMISSION CORPORATIONS BUREAU P.O. BOX 1269 SANTA FE NM 87504-1269 BIENNIAL REPORT_______ For taxable year ending_____/____/_______ OR SUPPLEMENTAL REPORT_______( if any information changes) Please see instructions on back of page. 1 EXACT CORPORATE NAME AND U.S. MAILING ADDRESS 2 Name Address City, State, Zip NMPRC Certificate of Incorporation No. 3 Principal Place of Business in New Mexico Street City, Zip 4 REGISTERED AGENT AND OFFICE LOCATION WITHIN NEW MEXICO FOR SERVICE OF PROCESS (Filing corporation cannot be its own agent) Name Street Address City, Zip 5 TAX ID NUMBER 6 NEXT ANNUAL MEETING 7 DIRECTORS AND OFFICERS List the names and addresses of ALL the directors and officers and identify every title each director holds. A New Mexico corporation shall consist of 1 or more directors. (optional) Term Office/Title Name Address Additional Titles Expires Director Director Director President Vice President Secretary Treasurer 8 SIGNATURE Under penalties of perjury, I declare and affirm that I have examined this report, including the accompanying schedules and statements, and that all statements contained therein are true and correct. Date Printed Name Signature Title 9 PAYMENT OF FILING FEE AND LATE FILING PENALTY a Report filing fee b Late filing penalty ($200.00) except supplemental IRS or PRC extension, if any, must be submitted with this report c TOTAL AMOUNT DUE with corporate report (lines a + b) PLEASE DO NOT SUBMIT CASH FOR PAYMENT NMPRC USE ONLY $ 25.00 Amount Remitted Postmark Date $ American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS This report is required by, and must comply with the requirements of, NMSA 1978 Sections 53-5-2 through 535-9 and 12.3.2.10 NMAC. A corporation must file a supplemental report if the corporation makes any change listed in NMSA 1978 Section 53-5-2. Please type or print legibly. At the top right of the form, indicate whether the report is a biennial or supplemental report, and the closing date of the taxable year of the report (if a biennial report). 1. Provide the exact name of the corporation and U.S. postal mailing address. If available, attach a mailing label from the Public Regulation Commission. 2. Insert the Certificate of Incorporation number issued by the Public Regulation Commission. 3. Provide the address of your principal place of business in New Mexico, or “NONE” if applicable. 4. Indicate the address of the registered office of the corporation in New Mexico, and the name of its registered agent at that address. For additional information on the requirements for registered office and agent, see NMSA 1978 Sections 53-11-11, 53-11-12, and 53-11-13. If within a municipality, the address must be a street address, or if outside a municipality must include geographic location, including well-known landmarks. 5. Insert the corporation’s taxpayer identification number issued by the revenue processing division of the taxation and revenue department. 6. Provide the date for the next annual meeting of shareholders for election of directors. 7. Indicate the names and respective addresses of the directors and officers of the corporation, and when their terms of office expire. You are not required to use the titles President, Vice President, Secretary and Treasurer, but you are required to have officers and you must indicate officers whose duties most closely correspond to the requirements of NMSA 1978 Section 53-11-48. If the corporation’s articles of incorporation or by-laws confer additional titles on the officers, you may provide these in the next to last column, but this is not required. Attach schedule of additional directors and officers if needed. 8. The chairman of the board, president, vice president, secretary, principal accounting officer, or authorized agent of the corporation must sign and swear to the statements in the report. 9. A biennial report is due on or before the fifteenth day of the third month following the end of the corporation’s taxable year (see Subsection C of 12.3.2.8 NMAC for information on determining your filing year). A supplemental report is due within thirty (30) days of the change necessitating the report. If not filed by these dates, you owe a late penalty of two hundred dollars ($200.00), unless the Commission granted an extension pursuant to NMSA Section 53-5-6. If the report is late and the Commission did not grant an extension, insert two hundred dollars ($200.00) in box 9b and total the fees owed. Payment of fees must accompany this report or the Commission will not accept it for filing. You may pay by check or money order made out to the New Mexico Public Regulation Commission. If the Commission granted an extension, you must attach a copy of the extension to this report. [12.3.2.10 NMAC - N, 7-15-05] American LegalNet, Inc. www.FormsWorkflow.com