Document processing fee If document is filed on paper $150.00 If document is filed electronically Currently Not Available Fees & forms/cover sheets are subject to change. To file electronically, access instructions for this form/cover sheet and other information or print copies of filed documents, visit www.sos.state.co.us and select Business. Paper documents must be typewritten or machine printed. ABOVE SPACE FOR OFFICE USE ONLY Statement of Election filed pursuant to §7-90-301, et seq. and §7-55-113 of the Colorado Revised Statutes (C.R.S) ID number: 1. Entity name: _____________________ ______________________________________________________ 2. A resolution adopted by its board of directors, its members, or its stockholders stating that the entity has elected not to become subject to the provisions of article 55 is attached. 3. (Optional) Delayed effective date: Notice: Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the individual's act and deed, or that the individual in good faith believes the document is the act and deed of the person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic statutes, and that the individual in good faith believes the facts stated in the document are true and the document complies with the requirements of that Part, the constituent documents, and the organic statutes. This perjury notice applies to each individual who causes this document to be delivered to the secretary of state, whether or not such individual is named in the document as one who has caused it to be delivered. 4. Name(s) and address(es) of the individual(s) causing the document to be delivered for filing: ______________________. (mm/dd/yyyy) ____________________ ______________ ______________ _____ (Last) (First) (Middle) (Suffix) ______________________________________________________ (Street number and name or Post Office Box information) ______________________________________________________ __________________________ _____ (City) (Province ­ if applicable) (State) ____________________ (ZIP/Postal Code) (Country) _______________________ ______________________________ (The document need not state the true name and address of more than one individual. However, if you wish to state the name and address of any additional individuals causing the document to be delivered for filing, mark this box name and address of such individuals.) and include an attachment stating the ELEC_55 Page 1 of 2 Rev. 6/16/2005 American LegalNet, Inc. www.FormsWorkFlow.com Disclaimer: This form, and any related instructions, are not intended to provide legal, business or tax advice, and are offered as a public service without representation or warranty. While this form is believed to satisfy minimum legal requirements as of its revision date, compliance with applicable law, as the same may be amended from time to time, remains the responsibility of the user of this form. Questions should be addressed to the user's attorney. ELEC_55 Page 2 of 2 Rev. 6/16/2005 American LegalNet, Inc. www.FormsWorkFlow.com Mail form with correct payment to: Colorado Secretary of State 1700 Broadway Ste 200 Denver, CO 80290 Make checks payable to: Colorado Secretary of State Include a separate check for each form submitted for filing. If a document is rejected, this will allow us to return the check at the time of rejection (if applicable). The document can be corrected and resubmitted with the returned check. Checks must be written for the exact amount or the document may be rejected and returned. Do not include this page with your filing. American LegalNet, Inc. www.FormsWorkFlow.com