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                                                      
                                                                                                SI-550 
                                    Statement of Information  
                                    (California Stock, Agricultural  
                                    Cooperative  and Foreign  
                                    Corporations) 

This form is due  within 90 days of initial registration and 
every year thereafter.
                                                                                 
Fees (Filing plus Disclosure) -                                      $25.00 
                                                                                                      
Certification Fee (Optional)                                      - $5.00                    
1. Corporation Name (Enter the exact name of the corporation as it                                                 This Space For Office Use Only 
     is recorded with the California Secretary of State. Note: If you                                         2.  Secretary    of State Entity Number 
     registered in California using an assumed name.) 

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

b. Mailing Address   of Corporation,if different than item 3a                                                 City (no abbreviations)  State           Zip Code 

c. Street Address of Principal                               California Office,   if any and if different     City (no abbreviations)  State           Zip Code 
     than Item 3a   -                       Do not list a P.O. Box
                                                                                                                                             CA  

                                                             The Corporation is required to list all three of the officers set forth below.  An additional title 
4. Officers                                                  for the Chief   Executive Officer and Chief Financial Officer  may be  added; however, the              
                                                             preprinted titles on this form must not be altered. 
a. Chief Executive Officer    First Name                                             Middle Name              Last Name                                    Suffix  

    Address                                                                                                   City (no abbreviations)  State           Zip Code 

b. Secretary                                                     First Name          Middle Name              Last Name                                    Suffix  

    Address                                                                                                   City (no abbreviations)  State           Zip Code 

c.Chief Financial Officer                                        First Name          Middle Name              Last Name                                    Suffix 

    Address                                                                                                   City (no abbreviations)  State           Zip Code 

SI-550 (REV03/2022)                                                                      (Page 1 of 2)                               2022   California Secretary of State 
                                                                                                                                             bizfileOnline.sos.ca.gov 

                                                     California Stock and Agricultural Cooperative Corporations ONLY:                            Item 5a: At least one 
5. Director(s)                                       name     and                     address  must  be  listed.  If  the  Corporation  has  additional  directors,
                                                     enter the name(s) and addresses on Form SI-550A. 

a. First Name                                                                                      Middle Name         Last Name                                      Suffix 

Address                                                                                                                City (no abbreviations)  State            Zip Code 

b. Number of Vacancies on the Board of Directors, if any

6. Service of Process                          (Must provide either IndividualOR 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 isnot a corporation)                                                 Middle Name             Last Name                     Suffix 

b. Street Address (if agent is not a corporation) - Do not                                                      City (no abbreviations)           State          Zip Code 
   enter a 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 Corporation 
                                                                                                                
8. Labor Judgment

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

9. 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.

The information contained herein, including in any attachments, is true and correct.  

_______________   _________________________________________________   _____________________   ____________________________
                                                                                                                             
Date                        Type or Print Name                                                                        Title                  Signature  
                                                                                                                                              
SI-550 (REV03/2022)                                                                                                                              202 2California Secretary of State 
                                                              (Page 2 of 2)                                     Clear Form   Print Form                  bizfileOnline.sos.ca.gov