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                         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 03/2022)                                             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

Does any Manager or Member have an outstanding final               judgment issued by the 
Division of Labor Standards Enforcement or a court of law,            for which no appeal                            Yes             No 
therefrom is pending, for      the violation of any wage order or 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 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.                                     

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 03/2022)                                                                                          202 2California Secretary of State 
                                       Page 2 of 2                    Clear Form            Print Form                bizfileOnline.sos.ca.gov