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-PC
                  Secretary of State 
                  Statement and Designation by 
                  Foreign Professional 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. Professional Statement
The purpose of this corporation is to engage in the profession of (check one):        Law         Accountancy 
This corporation is a foreign professional corporation within the meaning of Part 4, Division 3, Title 1, California Corporations Code.  The shareholders 
of this corporation shall be subject, with regard to the rendering of professional services by the professional corporation in California, or for California 
residents, to the same degree of personal liability, if any, in California as is from time to time prescribed by the agency governing the profession in this 
state for shareholders in a submission to the jurisdiction of the courts of California to the same extent, but only to the same extent, as applies to the 
shareholders of a California professional corporation rendering services in the same profession. This application accordingly constitutes a submission 
to the jurisdiction of the courts of California to the same extent, but only to the same extent, as applies to the shareholders of a California professional 
corporation in the same profession. The foregoing submission to jurisdiction is a condition of qualification to do business in this state. 

6. 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-PC (REV 07/2022)                                                                                                    20 22California Secretary of State   
                                                          Clear Form              Print Form                                      bizfileOnline.sos.ca.gov