RETURN TO: NM PUBLIC REGULATION COMMISSION CORPORATIONS BUREAU P.O. BOX 1269 SANTA FE NM 87504-1269 DOMESTIC NONPROFIT CORPORATION ANNUAL REPORT_________ For taxable year ending ____/____/_____ OR SUPPLEMENTAL REPORT________( if any information changes) See instructions on back of page. 1 Name EXACT CORPORATE NAME Address AND U.S. MAILING City, State, Zip ADDRESS 2 PRINCIPAL PLACE OF BUSINESS IN NEW MEXICO 3 NMPRC Certificate of Incorporation Number Street City, Zip 4 REGISTERED AGENT AND OFFICE LOCATION WITHIN NEW MEXICO FOR SERVICE OF PROCESS (Filing corporation cannot be its own agent) Name Street Address City, Zip 5 BRIEF STATEMENT OF CHARACTER OF AFFAIRS BEING CONDUCTED 6 DIRECTORS AND OFFICERS List the names and addresses of ALL the directors and officers and identify every title each director holds. A New Mexico non-profit corporation shall have not less than 3 directors. (optional) Office/Title Name Address Additional Titles Director Director Director President Vice President Secretary Treasurer Attach schedule of additional directors and officers if needed 7 SIGNATURES Under penalties of perjury, we declare and affirm that we have examined this report, including the accompanying schedules and statements, and that all statements contained therein are true and correct. Date 8 Printed Name PAYMENT OF FILING FEE AND LATE FILING PENALTY a Report filing fee b Late filing penalty ($10.00) except supplemental IRS or PRC extension, if any, must be submitted with this report c TOTAL AMOUNT DUE with corporate report (lines a + b) PLEASE DO NOT SUBMIT CASH FOR PAYMENT Signature Title NMPRC USE ONLY $ 10.00 Amount Remitted Postmark Date $ American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS This report is required by, and must comply with the requirements of, NMSA 1978 Sections 53-8-82 and 53-883 and 12.3.3.10 NMAC. Please print or type legibly. At the top right of the form, indicate whether this is an annual or supplemental report, and fill in the closing date of the corporation’s taxable year (if an annual report); you may find more information on determining your taxable year in 12.3.3.8 NMAC. 1. Provide the exact name of the corporation and U.S. postal mailing address. 2. Provide the address of your principal place of business in New Mexico, or “NONE” if applicable. 3. Provide the Certificate of Incorporation number issued by the Public Regulation Commission. 4. Indicate the address of the registered office of the corporation in New Mexico, and the name of its registered agent at that address. For additional information on the requirements for registered office and agent, see NMSA 1978 Sections 53-8-8 and 53-8-9. If within a municipality, the address must be a street address; if outside a municipality, you must include geographic location, including well-known landmarks. 5. Provide a brief statement of the character of the affairs that the corporation is actually conducting. Attach additional pages if necessary. 6. Indicate the names and respective addresses of the directors and officers of the corporation. You are not required to indicate who is the President, Vice President, Secretary and Treasurer, but you are required to have officers and you must indicate officers whose duties most closely correspond to the requirements of NMSA 1978 Section 53-8-23. If the corporation’s articles of incorporation or by-laws confer additional titles on the officers, you may provide these in the right column, but this is not required. 7. Any two of the directors or officers of the corporation, or a receiver or trustee if the corporation is in the hands of a receiver or trustee, must sign and swear to the statements in the report. 8. The Annual Report is due on or before the fifteenth day of the fifth month following the end of the corporation’s taxable year. A Supplemental Report is due within thirty (30) days of a change listed in NMSA 1978 Section 53-8-83. If not filed by this date, you owe a late penalty of ten dollars ($10.00), unless the Commission granted an extension pursuant to the terms of NMSA 1978 Section 53-8-83. If the report is late and the Commission did not grant an extension, insert ten dollars ($10.00) in box 8b, and total the fees owed. Payment of fees must accompany this report or the Commission will not accept it for filing. You may pay by check or money order made out to the New Mexico Public Regulation Commission. If the Commission granted an extension, you must attach a copy of the extension to this report. [12.3.3.10 NMAC - N, 7-15-05] American LegalNet, Inc. www.FormsWorkflow.com