Kentucky Secretary of State TREY GRAYSON _____________________________________________________________________________________________________ Division of Corporations BUSINESS FILINGS Application for Certificate of Authority FLC P.O. Box 718 Frankfort, KY 40602 (502) 564-2848 http://www.sos.ky.gov/ ___________________________________________________________________________ Pursuant to the provisions of KRS Chapter 275, the undersigned hereby applies for authority to transact business in Kentucky on behalf of the limited liability company named below and for that purpose submits the following statements: 1.The company is a limited liability company (LLC). a professional limited liability company (PLLC). 2. The name of the limited liability company is ________________________________________________________________________________. 3. The name of the limited liability company to be used in Kentucky is __________________________________________________________________________. (if "real name" is unavailable for use) 4._________________________________ is the state or country of organization. 5._________________________________ is the date of organization and, if the limited liability company has a specific date of dissolution, the latest date upon which the limited liability company is to dissolve is _____________________________. 6. The street address of the office required to be maintained in the state of formation or, if not so required, the principal office address is ________________________________________________________________________________. Street City State Zip Code 7. The names and usual business addresses of the current managers, if any, are as follows: ____________________________________ ___________________________________ Name Address _______________________________________ ___________________________________ Name Address (Attach a continuation, if necessary) 8. The street address of the registered office in Kentucky is ________________________________________________________________________________ Street City State Zip Code and the name of the registered agent at that office is ________________________________________________________________________________. 9. This application will be effective upon filing, unless a delayed effective date and/or time is specified: _______________________________________ (Delayed effective date and/or time) I certify that, as of the date of filing this application, the above-named limited liability company validly exists as a limited liability company under the laws of the jurisdiction of its formation. _____________________________________________ Signature _____________________________________________ Type or Print Name & Title Date:_______________________________, 20_______ I, ______________________________, consent to serve as the registered agent on behalf of the limited liability company. Type or print name of registered agent ____________________________________________________________________________ Signature of Registered Agent ____________________________________________________________________________ Type or Print Name & Title FLC (06/07) (See attached sheet for instructions) American LegalNet, Inc. www.FormsWorkflow.com Application for Certificate of Authority Filing Instructions TYPE OF COMPANY The limited liability company must indicate if it is a limited liability company or a professional limited liability company, by checking the appropriate box. LIMITED LIABILITY COMPANY NAME The limited liability company name must contain the words "limited liability company" or "limited company" or the abbreviations "LLC" or "LC". The word "limited" may be abbreviated as "Ltd." and the word "Company" may be abbreviated as "Co." The name of a professional limited liability company must contain the words "professional limited liability company" or "professional limited company" or the abbreviations "PLLC" or "PLC". The limited liability company must apply under its "real name" as filed in the state or country in which it is organized. If the "real name" is unavailable for use in Kentucky, the company must adopt a fictitious name for use in this state and attach a certificate of fictitious name executed by an authorized person. DATE OF ORGANIZATION AND DISSOLUTION The date of organization is the date articles of organization were filed with the secretary of state or other official having custody of the company’s records. If the limited liability company has a specific date of dissolution stated in its articles of organization, it is required to state the latest date upon which it is to dissolve. PRINCIPAL OFFICE ADDRESS The limited liability company is required to state the street address of the office required to be maintained in the state or other jurisdiction of its formation or, if not so required, the principal office of the foreign limited liability company. REGISTERED OFFICE AND REGISTERED AGENT The registered office of the limited liability company must be a Kentucky address and contain a street address or other specific location (Highway, Rural Route, Building etc.). A post office box only is insufficient for the registered office address. The registered agent may be an individual resident of Kentucky, a Kentucky corporation, a Kentucky nonprofit corporation, a Kentucky limited liability company or a foreign corporation, foreign limited liability company or foreign nonprofit corporation authorized to transact business in this state. The registered agent must be located at the registered office address. CONSENT OF REGISTERED AGENT The registered agent must sign the application giving written consent to act as agent on behalf of the limited liability company. If a corporation or a limited liability company (foreign or domestic) is acting as agent, the corporate or limited liability company representative must designate the title or capacity in which he or she signs. EFFECTIVE DATE AND TIME The document will be effective on the date and time of filing, unless a delayed effective date and/or time is specified. A th delayed effective date may not be later than the 90 day after the date of filing. WHO MAY SIGN If management of the limited liability company is vested in one or more managers, a manager must sign the application. If management is reserved to the members, a member must sign the application. The person executing the document must state his or her title or capacity in which he or she signs. NUMBER OF COPIES Submit the original signed application and two exact or conformed copies. (May be photocopies.) Two file-stamped copies will be returned to the limited liability company as evidence of filing. One file-stamped copy must then be filed with the county clerk of the county in which the limited liability company’s registered office is situated. NOTE: Your file-stamped copy shall serve as the Certificate of Authority. FILING FEES The filing fee is $90.00. Your check should be made payable to the "Kentucky State Treasurer". MAILING ADDRESS Trey Grayson Secretary of State P. O. Box 718 Frankfort, KY 40602-0718 OFFICE LOCATION 154, Capitol Building 700 Capital Avenue Frankfort, KY 40601 WEB SITE ADDRESS Our home page address is www.sos.ky.gov Click on “On Line Business Database” for information on status of all business entities in Kentucky. Forms are also available on our web site. For name availability, call (502) 564-2848, press 2, and then press 1. For further information, call (502) 564-2848, press 2, and the press 3 or try our web site. NOTE: If a Certificate of Authorization is needed, please attach a written request and submit an additional fee of $10.00. American LegalNet, Inc. www.FormsWorkflow.com