Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605)773-4845 ANNUAL REPORT FILE DATE FOREIGN 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 Authority was issued, and delinquent after the last day of the following month. 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) annualreportforeigncoop July 2010 American LegalNet, Inc. www.FormsWorkFlow.com