MINNESOTA SECRETARY OF STATE DOMESTIC COOPERATIVE PERIODIC REGISTRATION Minnesota Statutes Chapter 308A/308B Must be filed by December 31 File online at https://online.sos.state.mn.us/abr/corp_annual_filing.asp READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM CURRENT INFORMATION ON FILE: 1. File #: 2. Cooperative Name: (Required) 3. Registered Agent/ Registered Office Address: (Required) Street:____________________________________________________________________________________ (PO Box is not acceptable) City:______________________________________________State:_____________________Zip:____________ Agents Name: (if applicable) 4. Principal Place of Business Address: (Required) Address:_____________________________________________________________________________________ (PO Box isnot acceptable) City:______________________________________________State:_______________________Zip____________ 5. Name and Business Address of C.E.O.: (Required) Name:_______________________________________________________________________________________ Address:____________________________________________________________________________________ City:_____________________________________________State:_______________________Zip____________ 6. Does this cooperative own, lease, or have any financial interest in agricultural land or land capable of being farmed? Yes______ No______ 7. Name, daytime telephone number and e-mail address of contact person for the cooperative: Name: __________________________________________Phone(____)_________________ Ext. __________ E-Mail Address: ______________________________________________________________________________ NOTICE: Failure to file this form by December 31 of this year will result in the dissolution of this cooperative without further notice from the Secretary of State, pursuant to Minnesota Statutes, section 308A.995, subdivision 4, paragraph (b). American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING THIS FORM. All cooperative associations governed under Minnesota Statutes 308A/308B are required to file a periodic registration each odd numbered year. Items 2 and 3 are filed within the articles of incorporation; if there is a change to this information you must amend your articles of incorporation. The amendment form along with the $35.00 filing fee must be submitted at the same time as your periodic registration. You cannot use the periodic registration form to make changes to the articles of incorporation. Items 4 through 7 can be changed using the paper periodic registration form (in odd numbers years with our office). A cooperative that has been statutorily dissolved by our office may retroactively reinstate its existence by filing a single registration on paper and paying the $25.00 reinstatement fee. PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK. 1. File Number: Provide the cooperative charter number issued by the Minnesota Secretary of State. 2. Cooperative Name: (Required) List the cooperative name on file with the Secretary of State's office. 3. Registered Agent, if any and Registered Office Address: (Required) If changes to the registered agent name or address are necessary an amendment form and $35 fee must be included with the periodic registration. 4. Principal Place of Business Address: (Required) A full street address or rural route and rural route box number is required for filing the periodic registration. A post office box alone is not acceptable under the law. 5. Name and Business Address of Chief Executive Officer: (Required) Fill in the name and complete business address of the Chief Executive Officer or other person who carries out the functions as C.E.O. of the corporation. 6. Does the cooperative own, lease, or have any financial interest in agricultural land or land capable of being farmed? This question is optional. Check Yes or No. 7. Name, daytime telephone number and e-mail address of contact person for the cooperative: This information is optional. Please list a name, daytime telephone number and e-mail address of a person who can be contacted about this form. If this form is being mailed with an amendment form, please submit all items together and mail to the address below: FILE IN-PERSON OR MAIL TO: Minnesota Secretary of State - Renewals Retirement Systems of Minnesota Building 60 Empire Drive, Suite 100 St Paul, MN 55103 (Staffed 8:00 - 4:00, Monday - Friday, excluding holidays) File online at https://online.sos.state.mn.us/abr/corp_annual_filing.asp To obtain a copy of a form you can go to our web site at www.sos.state.mn.us , or contact us between 9:00am to 4:00pm, Monday through Friday at (651) 296-2803 or toll free 1-877-551-6SOS (6767). All of the information on this form is public. Minnesota law requires certain information to be provided for this type of filing. If that information is not included, your document may be returned unfiled. This document can be made available in alternative formats, such as large print, Braille or audio tape, by calling (651)296-2803/voice. For a TTY/TTD (deaf and hard of hearing) communication, contact the Minnesota Relay Service at 1-800-627-3529 and ask them to place a call to (651)2962803. The Secretary of State's Office does not discriminate on the basis of race, creed, color, sex, sexual orientation, national origin, age, marital status, disability, religion, reliance on public assistance or political opinions or affiliations in employment or the provision of service. bus23 Domestic Cooperatice Periodic Reg. Rev. 5-07 American LegalNet, Inc. www.FormsWorkflow.com