Amendment or Correction to Limited Cooperative Association Biennial Report , Secretary of State P.O. Box 94608 Lincoln, NE 68509 (402)471-4079 1)Exact Name of Limited Cooperative Association: 2)Foreign Limited Cooperative Association ONLY: Alternative Name: 3)Year(s) of Biennial Report to be amended or corrected: - Only complete the following information you wish to amend or correct. 4)Designated Office Address: Street Address City State Zip 5)Name and Street Address of the Agent for Service of Process in Nebraska: Name of Agent for Service of Process Street Address City State Zip 6)Principal Office Address: Street Address City State Zip Signature Printed Name Title Date FILING FEES: For Profit $30.00 (plus $5.00 for any additional pages) Nonprofit $10.00 (plus $5.00 for any additional pages) Make check payable to: Secretary of State Revised Neb. Rev. Stat. 247 21-2923 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING LIMITED COOPERATIVE ASSOCIATION AMENDMENT OR CORRECTION TO BIENNIAL REPORT The following information must be completed: 1. Exact Name of Limited Cooperative Association: As stated in the articles of organization, certificate of authority or most recent amendment. 2. Foreign Limited Cooperative Association ONLY: If you were required to choose an alternative name to use in Nebraska list the alternative name here. 3. Year(s) of Biennial Report to be amended or corrected. A separate form and fee must be submitted for each Biennial Report to be amended or corrected. Only complete the following information being amended or corrected: 4. Designated Office address: Provide complete street address. 5. Name and Street Address of Agent for Service of Process. Provide complete name and street address in Nebraska. 6. Principal Office Address: Provide complete street address. Page 2 American LegalNet, Inc. www.FormsWorkFlow.com