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

                                                                                  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.   

Processing Fee: $0 - The processing fee is waived for submissions 
submitted July 1, 2022 - June 30, 2023. 
Certification Fee (Optional) - $5.00
Note: The annual minimum $800 tax to the California Franchise Tax Board 
remains due and is not subject to the processing fee waiver. For more 
information, go to 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 07/2022)                                    Clear Form              Print Form                             20 22California Secretary of State 
                                                                                                                               bizfileOnlne.sos.ca.gov