ANNUAL LIST OF MANAGERS OR MANAGING MEMBERS AND REGISTERED AGENT AND STATE BUSINESS LICENSE APPLICATION OF: FILE NUMBER NAME OF LIMITED-LIABILITY COMPANY FOR THE FILING PERIOD OF *110403* TO **YOU MAY FILE THIS FORM ONLINE AT www.nvsos.gov** *110403* 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 IS FOUND AT: 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.) IMPORTANT: Read instructions before completing and returning this form. 1. Print or type names and addresses, either residence or business, for all manager or managing members. A Manager, or if none, a Managing Member of the LLC must sign the form. FORM WILL BE RETURNED IF UNSIGNED. 2. If there are additional managers or managing members, attach a list of them to this form. 3. Return completed form with the fee of $125.00. A $75.00 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. State business license fee is $200.00. Effective 2/1/2010, $100.00 must be added for failure to file form by deadline. 5. Make your check payable to the Secretary of State. 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. Failure to include annual list and business license fees will result in rejection of filing. ANNUAL LIST FILING FEE: $125.00 LATE PENALTY: $75.00 BUSINESS LICENSE FEE: $200.00 LATE PENALTY: $100.00 Complete only if applicable NRS 76.020 Exemption Codes Pursuant to NRS Chapter 76, this entity is exempt from the business license fee. Exemption code: 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. (DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) NAME MANAGER ADDRESS CITY STATE MANAGER CITY NAME ZIP CODE (DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) CITY NAME MANAGING MEMBER STATE ZIP CODE (DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) MANAGER ADDRESS ZIP CODE MANAGING MEMBER STATE MANAGER ADDRESS MANAGING MEMBER (DOCUMENT WILL BE REJECTED IF TITLE NOT INDICATED) NAME ADDRESS 001 - Governmental Entity 003 - Home-based Business 005 - Motion Picture Company 006 - NRS 680B.020 Insurance Co. CITY MANAGING MEMBER STATE ZIP CODE 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. X Signature of Manager or Managing Member Title Date Nevada Secretary of State Annual List ManorMem Revised: 7-5-11 American LegalNet, Inc. www.FormsWorkFlow.com