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

                                                         Instructions for Completing  the  
                                           Statement    of Information                            (Form LLC-12) 
Every California and registered foreign                           limited liability company must file a Statement   of Information 
with the California       Secretary of State, within 90 days                      ofregistering with the California Secretary of                        State,    
and every two years thereafter during a specific 6-month                                   filing period           based on  the original registration 
date, as described in the chart                    below. 

All Statements of Information                      for   limited   liability   companies can                be filed        onlineusing  our bizfile 
Online portal at bizfile nline.sos.ca.govO                       .
                                                                                                                                                                  
Status of LLC:        In order to file Form LLC-12,                    the status          of the   LLCmust  be active or suspended/forfeited 
on the records     of the         California       Secretary      of State. The status of the LLC                       can be checked  online on the             
Secretary of S tate’sBusiness             Search at           bizfileOnline.sos.ca.gov/search/business                        . See the  FTB 
Suspension/Forfeiture section below for information about resolving an FTB suspended/forfeited status. 
                                                                                                                                   
Fees: See chart below. Checks should be made payable to the Secretary of State. 
                                                                                                                                                                   
Copies:      Upon filing, we will return   one (1) plain copy of your filed document   for free and will certify   the                                           
copy upon  request and payment    of a $5 certification   fee.                                                                                           
                                                                                                                                                                 
Processing Dates:                 For current processing dates, go to www.sos.ca.gov/business/be/processing-dates. 

Type of 
                                           Description                                                             Online/Form                          Fee 
Filing 
Initial Filing       The initial filing is due 90 days from                                File online at bizfileOnline.sos.ca.gov                 .  $20.00 
                     the entity’s registration date.                                       (Form LLC-12)  

Required             •    The periodic filing is due every two                             File online at bizfileOnline.sos.ca.gov                 .   $20.00 
Periodic                  years based on the entity’s                                        (Form LLC-12, if changes have been 
Filing                    registration date.                                               made)                    
                     •    If the registration occurred in an                                     
                          even-numbered year, the periodic                                                                               
                          filing is due every even year.                                                                                   
                     •    If the registration occurred in an                                                            
                          odd-numbered year, the periodic
                          filing is due every odd year.
                     •    The filing period includes the
                          registration month              and the
                          immediately preceding five (5)
                          months.
No Fee               A Statement of Information is                                         File online at  bizfileOnline.sos.ca.gov.                   No Fee 
Statement            submitted after the initial or required                               (Form LLC-12) 
                     filing requirements have been met  to 
                     update information including changes  
                     to the agent for service of process. 

LLC-12 (REV    12/2022)                                                                                                           202 2 California Secretary of State 
                                                                                                                                        bizfile       Online.sos.ca.gov 

                 Statutory Required 6 Month Filing Window      for Limited Liability Companies 

               Month of Formation,                        Statement of Information 
               Registration or Conversion                 Applicable Filing Period     
                                                      First Day of         Through Last Day 
               January                                August                     January 
               February                               September                  February 
               March                                  October                        March 
               April                                  November                       April 
               May                                    December                       May 
               June                                   January                        June 
               July                                   February                       July 
               August                                 March                          August 
               September                                  April                  September 
               October                                    May                    October 
               November                                   June                   November 
               December                                   July                   December 

If you are not completing this form online, type or print    legibly in black or blue ink.  Complete the 
Statement of Information (Form LLC-12) as follows:         

Item  Instruction                                     Tips 
   1.      Enter the name of the limited liability    • To ensure you have the exact name of the LLC, refer
           company exactly as it appears on file          to your registration document filed with the California
           with the California Secretary  of State,       Secretary of State and any name change
           including the entity ending                    amendments.
           (ex: “Jones & Company,     LLC” or “Smith  • Some foreign LLCs may have registered in California
           Construction, a Limited Liability              using an alternate  name.   If your LLC is a registered
           Company”).                                     foreign LLC using an alternate name in California,
                                                          you must enter  the complete alternate name.

   2.      Enter the Entity Number   issued to  the   • The Entity (File)  Number    is provided by the               
           LLC by the    California Secretary of          Secretary of State above the file stamp at the top of 
           State at the time of registration.             the LLC’s registration document filed with the 
                                                          California Secretary of State  or if filed electronically, 
                                                          in the top section, below  the Entity Name.
                                                      • Secretary of State Records can be accessed online                
                                                          through our Business Search at
                                                          bizfileOnline.sos.ca.gov/search/business  . While            
                                                          searching the Business Search, be sure to identify 
                                                          your LLC correctly including  the jurisdiction       that   
                                                          matches your LLC.

   3.      If formed outside of California, enter     •   The jurisdiction must match the Secretary of State’s           
           the state, foreign country or other place      records.
           where the LLC   is organized.              •   Secretary of State Records can be accessed online              
                                                          through our Business Search at
                                                          bizfileOnline.sos.ca.gov/search/business  . While            
                                                          searching the Business Search, be sure to identify 
                                                          your LLC correctly including  the jurisdiction       that   
                                                          matches your registered foreign LLC.

LLC-12 (REV  12/2022)                                                                     202 2 California Secretary of State 
                                                                                                 bizfile       Online.sos.ca.gov 

Item  Instruction                                    Tips 
                                                     • If the LLC is  formed in California, leave Item 3 blank.

4a.        Enter the complete street address, city,  • The complete street address is required, including 
           state and zip code of the LLC’s             the street name and number, city, state and zip code.
                                                                 must be a physical address.
           principal  office.                        • Address 
                                                     • Do not enter a P.O. Box address, an “in care of”
                                                       address, or  abbreviate the name of the city.

4b.        If different from the address in Item 4a, • This address will be used for mailing purposes and
           enter the complete mailing address,         may be a P.O. Box address or “in care of” an
           city, state and zip code of  the LLC.       individual or entity.
                                                     • Do not abbreviate the name of  the city.

4c.        • If the LLC   is formed in California,   • The complete street address is required, including 
           enter the complete street address,          the street name and number,  city and zip code.
           city  and zip code of the office in       • Address  must be a physical address in California.
           California, if different from  Item 4a.
                                                     • Do not enter a P.O. Box  address, an “in care of”
           • If the LLC   is formed outside of         address, or abbreviate the name of the city.
           California, enter the complete street
           address, city and zip code of the         • If Item 4a is an address in California leave Item 4c
           principle  business office in California,   blank and proceed to Item 5.
           if any.

5.         Enter the name and complete business      • If the LLC has more than one manager or member,
           or residential address of  any              enter the name(s) and address(es)  of the additional
           manager(s), appointed or elected in         mangers or members on Form LLC-12A.
           accordance with the Articles of           • Please do not abbreviate the name of the city.
           Organization or Operating Agreement,  
           or if no manager(s) has been so           • Review your Articles of  Organization  or any
           elected or appointed, the name and          amendments thereto, to determine if the LLC   is run
           business or residential address of each     by a single manager, more than one manager or by
           member.                                     its member(s).
                                                     • Every LLC  is  required  to have at least one
                                                       manager/member.
                                                     • A member(s) is the owner of the LLC similar to             a
                                                       shareholder(s) in a corporation.

6.         The LLC must have an      Agent for       • An Agent for Service of  Process is responsible for
           Service of Process.                         accepting legal documents (e.g. service of process,
           There are two types of Agents that can      lawsuits, subpoenas, other types of legal notices,
           be named:                                   etc.) on behalf of the LLC.
           • an individual (e.g.,  member, manager,  • You must provide information for either  an individual
           or any other individual) who resides in     OR a registered corporate agent, not both.
           California with a physical California     • If using a registered corporate agent,  the corporation
           street  address; OR                         must have a current agent  registration certificate on
           • a registered corporate agent qualified    file with the California Secretary of State as required
           with the California Secretary of State.     by Section 1505.

6a & b.   If Individual Agent:                       • The complete street address is required, including 
           • Enter the name of the agent   for         the street name and number, city and zip code.
           service of process and the agent’s        • Do not  enter a P.O. Box address, an “in care of”
           complete California street address,         address, or abbreviate the name of the city.
           city and zip code.
                                                     • Many  times, a small LLC will designate a member or
LLC-12 (REV  12/2022)                                                                202 2 California Secretary of State 
                                                                                              bizfile       Online.sos.ca.gov 

Item  Instruction                                       Tips 
           • If an individual is designated as the        manager as  the agent for service of process.  
            agent, complete Items 6a and 6b             • The individual agent should be aware that  the name
            ONLY.  Do not complete Item 6c.               and the physical street address of  the agent for
                                                          service of process is a  public record, open to all (as
                                                          are  all the addresses of the LLC provided in filings).

6c.        If Registered Corporate Agent  :             • Before a corporation is designated as agent for the
                                                        LLC, that corporation must have a current agent
           • Enter  the name of the registered
                                                        registration certificate on file with the California
            corporate agent exactly  as registered                                                   
                                                        Secretary of State as required by Section 1505 stating
            in California.                                                                                                          
                                                        the address(es) of the registered corporate agent and
           •
            If a registered corporate agent is          the authorized employees that will accept service of
            designated as the agent, complete           process of legal documents and notices on behalf of
            Item  6c ONLY.  Do not complete             the LLC.
            Items 6a and 6b.
                                                        • Advanced approval  must be obtained   from a
                                                        registered corporate agent  prior   to designating that
                                                        corporation as your agent for service of process.
                                                        • No California or foreign corporation may register as
                                                        California corporate agent unless the corporation
                                                        currently is authorized to engage in business in
                                                        California and is in good standing on the records of                         the
                                                        California Secretary of State. 
                                                        • Provide your Registered Corporate Agent’s exact
                                                        name as registered with the California Secretary of
                                                        State. To confirm that you are providing the exact
                                                        name of the Registered Corporate              Agent, go to                  
                                                        bizfile nline.sos.ca.gov/search/businessO              .

7.         Briefly describe the general type of 
           business that is the principal business  
           activity of the LLC. 

8.         Enter  the name and complete business        • A chief executive officer  may be in addition to
           or residential address of the chief            members and managers but generally is the person
           executive officer, if any.                     that occupies  the highest level position in the LLC’s
                                                          organization hierarchy in charge of managing the
                                                          LLC.

9.         Check either YES or NO      to disclose   if   Manager-managed            California    or manager-managed 
           any Manager or any Member have an              Out- -of State LLC    : does any manager have     an 
           outstanding final judgment issued by           outstanding final judgment issued by the Division o                       f
           the Division of Labor Standards                Labor Standards Enforcement or a court of law, for 
           Enforcement or a court of law, for             which no appeal therefrom is pending, for the violation 
           which no appeal is pending, for the            of any wage order or provision of the Labor Code?
           violation of any wage order or provision 
                                                                                
           of the Labor Code.                             Member-managed California LLC: does any 
                                                                                 
                                                          managing member have an outstanding final judgment 
                                                                                          
                                                          issued by the Division of Labor Standards 
                                                          Enforcement or court of law, for which no appeal 
                                                                                          
                                                          therefrom is pending, for the violation of any wage 
                                                                                      
                                                          order or provision of the Labor Code?
    
                                                          NOTE: Pursuant to California Corporations Code 
                                                          section   17701.10(d), if a written operating agreement

LLC-12 (REV   12/2022)                                                                            202 2 California Secretary of State 
                                                                                                               bizfile       Online.sos.ca.gov 

                                                       limits the members who are agents of the limited                     
                                                       liability company for the purpose of its business 
                                                       and affairs to a specified member or specified                                 
                                                       members, answer this question with respect to the 
                                                       specified member or members only.
                                                                                                                                     
                                                       Out- -of State LLC that is not managed by a 
                                                                                    
                                                       manager or managers: does any member have 
                                           
                                                       an outstanding final judgment issued by the 
                                                       Division of Labor Standards Enforcement or court 
                                                       of law, for which no appeal is pending, for the   
                                                       violation of any wage order or provision of the 
                                                       Labor Code?                                                                 
                                                               
                                                        NOTE: Answer this question             as to     the specified            
                                                       member or members  that are agents   of the                          out-of-   
                                                       state  limited liability company for purposes of its 
                                                       business and affairs only.

                                                       If the answer to any of the questions above is Yes, 
                                                       select the Yes option. Otherwise, select No. 

10.        Type or print the date, the name and 
           title of the person completing this form 
           and sign where indicated. 

Submission Cover Sheet (Optional): Complete and include with your paper submission. This information 
will be used to communicate with you about the submission, if needed. This submission cover sheet will be 
treated as correspondence and will not be made part of the filed document. 
Where to File:     For faster service, this form can befiled onlineatbizfileOnline.sos.ca.gov                . The completed 
form along with the applicable fees can be mailed to Secretary of State, Statement of Information Unit, 
P.O. Box 944260, Sacramento, CA  94244-2600 or delivered in person (drop off) to the Sacramento office, 
1500 11th Street, Sacramento, CA  95814. 
Legal Authority:        General statutory filing provisions are found in Section 17702.09 unless otherwise 
indicated. All statutory references are to the California Corporations Code, unless otherwise stated. 
Failure to file this Statement of Information by the due date will result in the assessment of a $250.00 
penalty. (Sections 17713.07(b) and 17713.09; California Revenue and Taxation Code section 19141.) 
FTB Suspension/Forfeiture:       If the LLC’s status is FTB suspended/forfeited, the status must be resolved 
with the California Franchise Tax Board (FTB) for the LLC to be returned to active status. For revivor 
requirements, go to the FTB’s website at https://www.ftb.ca.gov or contact the FTB at (800) 852-5711 
(from within the U.S.) or (916) 845-6500 (from outside the U.S.). 

LLC-12 (REV  12/2022)                                                                            202 2 California Secretary of State 
                                                                                                             bizfile       Online.sos.ca.gov 

                     Secretary of State                        LLC-12 
                     Statement of Information  
                     (Limited Liability Company) 

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

Filing Fee - $20.00  
                                                                        
Certification Fee (Optional)   -$5.00
                                                                
                                                                                    This  Space For Office Use Only  

1. Limited Liability Company Name           (Enter the exact name of the LLC.  If you registered in California using an
   alternate name.) 

2. Secretary of State Entity      Number                       3. State, Foreign Country or Place of Organization
                                                                       (only if formed outside of California)

4. Business Addresses
a. Street Address of Principal Office - Do not list a P.O. Box           City (no abbreviations)             State  Zip Code      

b. Mailing Address of LLC,      if different than item 4a                City (no abbreviations)             State  Zip Code      

c. Street Address of California Office, if Item 4a is not in California  City (no abbreviations)             State  Zip Code      
   Do not list a P.O.  Box
                                                                                                             CA  

5. Manager(s)  or Member(s)             If no managers have been appointed or elected, provide the name and address of  
                                        each member. At least one name and address must be listed. If the 
                                        manager/member is an individual, complete Items 5a and 5c (leave Item 5b blank). 
                                        If the manager/member is an additional managers/members, enter the names(s) 
                                        and address(es) on Form LLC-12A   . 
a. First  Name, if an individual -   Do not complete Item 5b           Middle Name       Last Name                               Suffix  

b. Entity  Name - Do not complete Item 5a

c. Address                                                               City  (no abbreviations)            State  Zip Code  

LLC-12 (REV 12/2022)                                       Page 1 of 2                                       2022   California Secretary of State 
                                                                                                                    bizfileOnline.sos.ca.gov 

6. Service of Process                 (Must provide either Individual OR Corporation.)
     INDIVIDUAL              – Complete         Items 6a and 6b 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                 City (no abbreviations)     State    Zip Code          
    P.O. Box
                                                                                                                                  CA  

    CORPORATION                  – Complete Item 6c 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 6a or 6b 

7. Type of  Business
Describe the type of        business or services of the Limited Liability Company 

8. Chief       Executive Officer, if elected                 or appointed
a. First Name                                                                              Middle Name            Last Name                             Suffix  

b. Address                                                                                            City  (no abbreviations)    State    Zip Code  

9. Labor Judgment (See instructions)

Does a Manager or Member, as further defined by California  orporations Code                 C
                                                                                                                   
section17702.09(a)(8), have an outstanding final judgment issued by the  ivision                               D
of Labor Standards Enforcement or a court of law, for which no appeal is pending,                                                        Yes              No 
                                                                                                                 
for the violation of any wage order of provision of the Labor Code?

10.0. Email Notifications                                                                                                                          

Provide an email address to opt-in to receive entity related notifications, including Statement of Information 
reminders, by email rather than mail.USPS 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.                                                                 

By signing, I affirm under penalty of perjury that the information herein is true and correct and that I am 
authorized by California law to sign.

_____________________ ____________________________________________________________                    ________________________ __________________________________ 
Date                  Type or Print Name                                                              Title                      Signature 
LLC-12 (REV 12/2022)                                                                                                              202 2California Secretary of State 
                                                      Page 2 of 2                          Clear Form            Print Form                bizfileOnline.sos.ca.gov