Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605)773-4845 ANNUAL REPORT FILE DATE DOMESTIC Cooperative ____________________ RECEIPT NO ___________________ Please Type or Print Clearly in Ink FILING FEE: $50 Make check payable to SECRETARY OF STATE 1. Corporate ID and Name: Telephone # ____________________ FAX # _______________________ FILING DATE: Due during the month the Certificate of Incorporation was issued, and delinquent after the last day of the following month. South Dakota 2. The jurisdiction under whose law it is formed __________________________________________________________ 3. The address of the principal executive office in or out of the State of South Dakota. ______________________________________________________________________________________________ Street Address City State ZIP+4 ______________________________________________________________________________________________ Mailing Address (Optional) City State ZIP+4 4. The name of the South Dakota Registered Agent _______________________________________________________ ______________________________________________________________________________________________ Street Address (Required to be a South Dakota Address) City State ZIP+4 ______________________________________________________________________________________________ Mailing Address (Optional – Required to be a South Dakota Address) City State ZIP+4 5. The names and business addresses of its principal officers and directors. Please place a check mark next to the name if the principal officer serves as a director. _____________________________________________________________________________________________ President Street Address City State ZIP+4 _____________________________________________________________________________________________ Vice President Street Address City State ZIP+4 _____________________________________________________________________________________________ Secretary Street Address City State ZIP+4 _____________________________________________________________________________________________ Treasurer Street Address City State ZIP+4 _____________________________________________________________________________________________ Director Street Address City State ZIP+4 _____________________________________________________________________________________________ Director Street Address City State ZIP+4 _____________________________________________________________________________________________ General Manager Street Address City State ZIP+4 No person may execute this report knowing it is false in any material respect. Any violation is subject to a civil penalty. Dated ____________________________ ______________________________________________ (Signature of an Authorized Person) ______________________________________________ (Printed Name) annualreportdomesticcoop July 2010 American LegalNet, Inc. www.FormsWorkFlow.com