Version 1; 04-06-09 District of Columbia Government Corporations Division PO Box 92300 Washington DC 20090 BRA-27. Annual Report for Domestic and Foreign Cooperative Association Use this form to file an Annual Report for a Domestic or Foreign Cooperative Association (Co-op). ENTITY TYPE FILING FEE Cooperative Association File Number DEADLINE $0.50 1. Entity Name Year of Filing ENTITY E-MAIL ADDRESS 60 days after the end of fiscal year 2. Cooperative association's principal address 3. List all corporation directors and officers (attach sheet if needed) TITLE OCCUPATION NAME ADDRESS COMPENSATION TERM EXPIRATION DATE AUTHORIZED SUBSCRIBED PAID-IN ADMITTED DURING YEAR WITHDRAWN DURING YEAR TOTAL NOW CAPITAL RETURN RATE PAID PAR VALUE PER SHARE TOTAL PAR VALUE EXPENDITURES LIABILITIES ASSETS WITHDRAWN DURING YEAR TOTAL TOTAL MEMBERSHIP FEES 4. Amount and nature of capital 5. Shareholders 6. Shares 7. Financial (You may attach your audit statement to meet this RECEIPTS requirement.) 8. Operations closing date NON-SHARE ASSOCIATIONS ONLY: Complete question 9. 9. Members ADMITTED DURING YEAR President / Vice-President executing this form (required) Signature Secretary / Assistant Secretary executing this form (required) Signature If you sign anywhere on the Annual Report Form, you agree that you understand that anyone who makes a false statement anywhere on it can be punished by criminal penalties of a fine up to $1000, imprisonment up to 180 days, or both, under DCOC § 222405. Mail all forms and required payment to: Department of Consumer and Regulatory Affairs Corporations Division PO Box 92300 Washington, DC 20090 Phone: (202) 442-4400 For overnight delivery send to: Corporate Bank of America Attention: DC Government Wholesale Lockbox #92300 Mail Code MD4-301-18-04 225 North Calvert Street - 18 th floor Baltimore, Maryland 21202 Please check dcra.dc.gov to view organizations required to register, to search business names, to get step-by-step guidelines to register an organization, to search registered organizations, and to download forms and documents. Just click on Corporate Registrations." American LegalNet, Inc. www.FormsWorkFlow.com