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Annual List Of Officers Directors And Resident Agent Of Nonprofit Corporation Form. This is a Nevada form and can be use in Corporation Secretary Of State.
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(NONPROFIT) ANNUAL LIST OF OFFICERS, DIRECTORS AND REGISTERED AGENT OF
FILE NUMBER
NAME OF CORPORATION
FOR THE FILING PERIOD OF
*110203*
TO
*110203*
The entity's duly appointed registered agent in the State of Nevada upon whom process can be served is:
A FORM TO CHANGE REGISTERED AGENT INFORMATION CAN BE FOUND ON OUR WEBSITE:
www.nvsos.gov
USE BLACK INK ONLY - DO NOT HIGHLIGHT
ABOVE SPACE IS FOR OFFICE USE ONLY
Return one file stamped copy. (If filing not accompanied by order instructions, file stamped copy will be sent to registered agent.)
**YOU MAY NOW FILE YOUR ANNUAL LIST ONLINE AT www.nvsos.gov**
IMPORTANT: Read instructions before completing and returning this form.
1. Print or type names and addresses, either residence or business, for all officers and directors. A President, Secretary, Treasurer, or equivalent of and all Directors must be
named. There must be at least one director. An Officer must sign the form. FORM WILL BE RETURNED IF UNSIGNED.
2. If there are additional officers, attach a list of them to this form.
3. Return the completed form with the $25.00 filing fee, if no capitalization. A $50.00 penalty must be added for failure to file this form by the deadline. An annual list received
more than 90 days before its due date shall be deemed an amended list for the previous year.
4. Nonprofit entities formed under NRS Chapters 80 and 81 without 501(c) nonprofit designation are required to maintain a state business license. Those with 501(c) designation
must indicate by checking box below. For those requiring a State Business License, the fee is $200.00.
5. Make your check payable to the Secretary of State. Your canceled check will constitute a certificate to transact business.
6. Ordering Copies: If requested above, one file stamped copy will be returned at no additional charge. To receive a certified copy, enclose an additional $30.00 per certification.
A copy fee of $2.00 per page is required for each additional copy generated when ordering 2 or more file stamped or certified copies. Appropriate instructions must
accompany your order.
7. Return the completed form to: Secretary of State, 202 North Carson Street, Carson City, Nevada 89701-4201, (775) 684-5708.
8. Form must be in the possession of the Secretary of State on or before the last day of the month in which it is due. (Postmark date is not accepted as receipt date.) Forms
received after due date will be returned for additional fees and penalties.
FILING FEE: $25.00 (IF NO CAPITALIZATION)
LATE PENALTY: $50.00
For NRS Chapter 80 and 81 nonprofit corporations:
Pursuant to NRS Chapter 76, this entity is a 501(c) nonprofit entity and is exempt from the business license fee.
NOTE: If claiming an exemption, a notarized Declaration of Eligibility form must be attached. Failure to
attach the Declaration of Eligibility form will result in rejection, which could result in late fees.
NAME
TITLE(S)
ADDRESS
CITY
NAME
Exemption code 002
TITLE(S)
PRESIDENT (OR EQUIVALENT OF)
STATE
ZIP CODE
SECRETARY (OR EQUIVALENT OF)
ADDRESS
CITY
STATE
NAME
ZIP CODE
TITLE(S)
TREASURER (OR EQUIVALENT OF)
ADDRESS
CITY
STATE
NAME
TITLE(S)
ADDRESS
CITY
ZIP CODE
STATE
ZIP CODE
DIRECTOR
I declare, to the best of my knowledge under penalty of perjury, that the above mentioned entity has complied with the provisions of NRS Chapter 76 and
acknowledge that pursuant to NRS 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing in the Office of the Secretary of
State.
Title
Date
X
Signature of Officer
Nevada Secretary of State Annual List Nonprofit
Revised: 7-5-11
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