Secretary of State 
                                                                Business Programs Division 
                                                                            Business Entities 
                                                   1500 11th Street, Sacramento, CA 95814 
                                               P.O. Box 944260, Sacramento, CA 94244-2600 

                                                   Submission Cover Sheet

For faster service, file online at bizfileOnline.sos.ca.gov               . 

Instructions: 

• Complete and include this form with your paper submission. This information only will be
  used to communicate in writing about the submission, if needed. This form will be
  treated as correspondence and will not be made part of the filed document.

• Make all checks or money orders payable to the Secretary of State.

• In person submissions (excluding Statements of Information): $15 handling fee; do not include
  a $15 handling fee when submitting documents by mail.

• Standard processing time for submissions to this office is approximately 5 business days from
  receipt. All submissions are reviewed in the date order of receipt with online submissions
  given priority. For updated processing time information, visit
  www.sos.ca.gov/business/be/processing-dates.

Optional Copy and Certification Fees: 

• If applicable, include optional certification fees with your submission.

• For applicable certification fee information, refer to the instructions of the specific form you are
  submitting.

Contact Person: (Please type or print legibly) 

First Name:                                     Last Name: 

Phone (optional):  

Entity Information: (Please type or print legibly) 

Name:  

Entity Number (if applicable):  

Address: 

Comments

Submission Cover Sheet (REV 03/2022)                            Clear Form  Print Form

            Secretary of State                      SI-100 
            Statement of Information 
            (California Nonprofit, Credit Union and 
            General Cooperative Corporations) 

This form is due within 90 days of initial registration and 
every two years thereafter.  

Filing Fee – $20.00      

Certification Fee (Optional) – $5.00

1. Corporation Name (Enter the exact name of the
   corporation as it is recorded with the California Secretary of This Space For Office Use Only 
   State)
                                                                  2. Secretary of State Entity Number

3. Business Addresses

a. Street Address of California Principal Office, if any - Do not City (no abbreviations) State  Zip Code 
enter a P.O. Box

                                                                                          CA 

b. Mailing Address of Corporation, if different than item 3a      City (no abbreviations) State  Zip Code 

                    The Corporation is required to enter the names and addresses of all three of the officers set forth 
4. Officers         below.  An additional title for Chief Executive Officer or Chief Financial Officer may be added; 
                    however, the preprinted titles on this form must not be altered. 

a. Chief Executive Officer/   First Name Middle Name              Last Name                          Suffix 

    Address                                                       City (no abbreviations) State  Zip Code 

b. Secretary/        First Name          Middle Name              Last Name                          Suffix 

    Address                                                       City (no abbreviations) State  Zip Code 

c. Chief Financial Officer/   First Name Middle Name              Last Name                          Suffix 

    Address                                                       City (no abbreviations) State  Zip Code 

SI-100 (REV 03/2022)                     Page 1 of 2                                      2022 California Secretary of State 
                                                                                              bizfile.sos.ca.gov 

5. Service of Process (Must provide either Individual OR Corporation.)

INDIVIDUAL – Complete Items 5a and 5b only.  Must include agent’s full name and California street
address.

a. California Agent's First Name (if agent is not a      Middle Name           Last Name                 Suffix 
corporation)

b. Street Address (if agent is not a corporation) - Do   City (no abbreviations)               State  Zip Code 
not enter a P.O. Box
                                                                                               CA 

CORPORATION – Complete Item 5c only.  Only include the name of the registered agent Corporation. 

c. California Registered Corporate Agent’s Name (if agent is a corporation) – Do not complete Item 5a or 5b

6. Common Interest Developments

Check here if the corporation is an association formed to manage a common interest development under 
the Davis-Stirling Common Interest Development Act (California Civil Code section 4000, et seq.) or under 
the Commercial and Industrial Common Interest Development Act (California Civil Code section 6500, et 
seq.).  The corporation must file a Statement by Common Interest Development Association (Form SI-CID) 
as required by California Civil Code sections 5405(a) and 6760(a).   

7. Email Notifications

Provide an email address to opt-in  to receive entity related notifications, including Statement of 
Information reminders, by email rather than USPS mail. Note: If no email address is provided, you will          
continue to receive  notices and reminders by USPS mail.

Yes, I opt-in to receive entity notifications via email. Email Address: ______________________________________________ 

To change your option after filing, you must submit a new complete Statement of Information. 

The Information contained herein, including in any attachments, is true and correct. 

_________________    _________________________________________________ ____________________    __________________________
 Date                 Type or Print Name                                 Title                 Signature 

                                              Page 2 of 2

SI-100 (REV 03/2022)              Clear Form           Print Form                              2022 California Secretary of State 
                                                                                                         bizfile.sos.ca.gov