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

                                    Business Entities Submission Cover Sheet

                                For faste stservice, file online at      bizfileOnline.sos.ca.gov. 

Instructions: 

• Complete and include this form with your paper submission. This form 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                      special handling fee  D. o not
  include                       a $15 special handling fee when submitting documents by mail.

• 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.

•    obtainTo a certified copy,               includ ecertification fees with your submission.

                                Note: All correspondence related to your submission will be 
                                sent to the name and address on your check or money order.

Contact Person                        (Please type or print legibly): 

First Name:                                                      Last Name: 

Phone Number:                                                   Email:

Entity Information (Please type or print legibly): 

Entity Name:  

Entity Number (if applicable): 

Comments: 

                                                                                     Clear Form Print Form
Submission Cover Sheet (REV 03/2024) 

                                                                                  S&DC-S/N
                   Secretary of State 
                   Statement and Designation by 
                   Foreign Corporation 

Must be submitted with a current Certificate of Good Standing issued by the 
government agency where the corporation was formed.   

Filing Fee –  $100.00 (for a foreign stock corporation) or
                $30.00 (for a foreign nonprofit corporation)    
Certified Copy Fee (Optional) - $5.00
Note: Corporations may have to pay minimum $800 tax to the California 
Franchise Tax Board each year. For more information, go to 
https://www.ftb.ca.gov/.
                                                                                                              This Space For Office Use Only 

 1. Corporate Name (Go to www.sos.ca.gov/business/be/name-reservations                                                   (State,  foreign country  or place
                                                                                                  2. Jurisdiction
                                                                                                              where this corporation is formed  - must match
   for general corporate name requirements and restrictions.)                                                 the Certificate of Good Standing provided.)

3. Business Addresses (Enter the complete business addresses. Items 3a and 3b cannot be a P.O. Box or “in care of” an individual or entity.)

a. Initial Street Address of Principal Executive Office - Do not enter a P.O. Box     City (no abbreviations)            State Zip Code 

b. Street Address of Principal Office in California, if any - Do not enter a P.O. Box City (no abbreviations)            State Zip Code 
                                                                                                                         CA 
 c. Mailing Address of Principal Executive Office, if different than item 3a          City (no abbreviations)            State Zip Code 

4. Service of Process (Must provide either Individual OR Corporation.) 
   INDIVIDUAL – Complete Items 4a and 4b only.  Must include agent’s full name and California street address.
a. California Agent's First Name (if agent is not a corporation)                      Middle Name             Last Name                            Suffix 

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

                                                                                                                         CA 
   CORPORATION – Complete Item 4c.  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 4a or 4b 

5. Read and Sign Below            (Office or title not required. )
I am a corporate officer and am authorized to sign on behalf of the foreign corporation.

  __________________________________________________________                            ____________________________________________________ 
 Signature                                                                              Type or Print Name

S&DC-S/N (REV 06/2023)                                    Clear Form              Print Form                             20 23California Secretary of State 
                                                                                                                               bizfileOnlne.sos.ca.gov