Office of the Minnesota Secretary of State Assumed Name | Annual Renewal Must be filed by December 31 Read the instructions before completing this form. Current Information on File: (If changes are needed, see instructions for further details.) 1. File Number: 2. Assumed Name: (Required) 3. Principal Place of Business Address: (Required) Street Address City State Zip Code Minnesota Statutes, Section 5.34 Email Address for Official Notices Enter an email address to which the Secretary of State can forward official notices required by law and other notices: Check here to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law. List a name and daytime phone number of a person who can be contacted about this form: Contact Name Phone Number Entities that own, lease, or have any financial interest in agricultural land or land capable of being farmed must register with the MN Dept. of Agriculture's Corporate Farm Program. Does this entity own, lease, or have any financial interest in agricultural land or land capable of being farmed? Yes No NOTICE: Failure to file this form by December 31 of this year will result in the expiration of this assumed name without further notice from the Secretary of State, pursuant to Minnesota Statutes, section 333.055. American LegalNet, Inc. www.FormsWorkFlow.com Office of the Minnesota Secretary of State Assumed Name | Annual Renewal Minnesota Statutes, Section 5.34 Minnesota Business Snapshot To better serve Minnesotans, the Secretary of State's Office has created the "Minnesota Business Snapshot," a short and simple survey produced with the input of business owners, business organizations, non-profits, and researchers from across the state. These five questions will take less than three minutes to complete, and you may answer any or all of them. There is no penalty if you choose not to provide this information. However, the answers you do provide will create a useful pool of information for potential customers and inform the analysis of our quarterly "Minnesota Economic and Business Condition Reports". We do not independently verify the answers applicants provide. Again, this survey is voluntary and the answers are considered public data. Thank you. 1. (Select up to one) - How many Minnesota ­ based full time employees (or FTE equivalents) does this entity currently have? 0-5 6-50 51-200 201-500 Over 500 2. (Select all that apply) - Does the owner or a member of the ownership group of this entity self-identify as a member of any of the following communities? Woman Member of a community of color Veteran Member of a disability community Member of an immigrant community 3. (Select up to one) - Using NAICS codes below, please select the code that best describes this entity. If you believe this entity falls into more than one category, please select the category that generates the majority of the entity's revenue. Agriculture, Forestry, Fishing and Hunting (Code 11) Mining (Code 21) Utilities (Code 22) Construction (Code 23) Manufacturing (Codes 31-33) Wholesale Trade (Code 42) Retail Trade (Codes 44-45) Transportation and Warehousing (Codes 48-49) Information (Code 51) Finance and Insurance (Code 52) Real Estate Rental and Leasing (Code 53) Professional, Scientific, and Technical Services (Code 54) Management of Companies and Enterprises (Code 55) Administrative and Support and Waste Management and Remediation Services (Code 56) Educational Services (Code 61) Health Care and Social Assistance (Code 62) Arts, Entertainment, and Recreation (Code 71) Accommodation and Food Services (Code 72) Other Services (except Public Administration) (Code 81) Public Administration (Code 92) 4. (Select up to one) Is this entity a full time or part time endeavor for those primarily responsible for operating this entity? Full time Part time 5. (Select up to one) - If applicable, what were this entity's gross revenues for the past year? $0 - $10,000 $10,001 - $50,000 $50,001 - $250,000 $250,001 - $1M Over $1M American LegalNet, Inc. www.FormsWorkFlow.com AssumednamerenewalRev.3/21/2017 INSTRUCTIONS File your business document online by visiting our website at https://mblsportal.sos.state.mn.us/Business/Search All assumed names governed under Minnesota Statutes, Chapter 333 are required to file an annual renewal once every calendar year after the time of expiration of their ten year term (effective in 2011). The annual renewal will be filed for the calendar year in which the current expiration date is listed. Filing this Annual Renewal does not satisfy any other legal requirement. If Minnesota statutes or rules require a filing with another office, you must submit that filing separately. If changes to the assumed business name or principal place of business address are necessary, an amendment form along with the applicable filing fee must be included with the annual renewal form. Note: You cannot use the annual renewal form to make changes to your Certificate of Assumed Name. 1. File Number: List the file number issued by the Office of the Secretary of State. 2. Assumed Name: (Required) List the business name on file with the Secretary of State's office. 3. Principal Place of Business Address: (Required) List the Principal Place of Business Address on file with the Secretary of State's office. Email Address for Official Notices. This email address may be used to send annual renewal reminders and other important notices that may require action or response. Check the box if you wish to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law. List a name and daytime telephone number of a person who can be contacted about this form. Minnesota Business Snapshot. This information is a snapshot of data at the point of time this filing was made. This information is voluntary and may be shared with other agencies or the public for data analysis. There is no fee for filing the annual renewal if the Assumed Name is active and in good standing. An Assumed Name that has expired for failure to file an annual renewal may retroactively reinstate its existence by filing the current year's renewal and paying a $45 for expedited service in-person and online filings, $25 if submitted by mail. Payable to the MN Secretary of State. Please submit all items together and mail to the address below: FILE IN-PERSON OR MAIL TO: Minnesota Secretary of State - Business Services Retirement Systems of Minnesota Buil