Secretary of State Office 
500 E Capitol Ave                                 ANNUAL REPORT 
Pierre, SD 57501 
                                    FOREIGN BUSINESS  ORPORATIONC                
(605)773-4845                                         SDCL 59-11-24, 24.1
corpinfo@state.sd.us

                                                      FILING FEE: $65
                                    Additional Fee for Delinquent Reports: $50
Enter Filing Year 

1. Business ID and Name:

Business ID 

Business Name 

2. The jurisdiction under whose law it is formed

3. The address of the principal executive office (business address).

Actual Street Address                                                      City  State ZIP+4 

Mailing Address, if Different from Street Address                          City  State ZIP+4 

Email Address (Optional) 

4. The South Dakota Registered Agent’s name
South Dakota law permits the registered agent to be either: A)                noncommercial registered agent (this may be an
individual), B) a commercial registered agent, or C) an office holder.  Complete only one below, either (a) or (b) or (c).

(a) The South Dakota Noncommercial Registered Agent’s name

Actual Street Address in this State                                        City  State ZIP+4 

Mailing Address in this State, if Different from Street Address            City  State ZIP+4 

Email Address (Optional) 

(b) When listing a Commercial Registered Agent, please state their CRA#. This number can be obtained from the
    Commercial Registered Agent.

Commercial Registered Agent Name                                                 CRA# 

(c) Title of the office or other position with the corporation

Business Office’s Actual Street Address in this State                      City  State ZIP+4 

Mailing Address in this State, if Different from Street Address            City  State ZIP+4 

Email Address (Optional) 

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5. The names and business addresses of its principal officers and directors (governors). If, pursuant to SDCL 47-1A-732(1),
the board of directors has been eliminated, list the names of the shareholders.

Shareholder/Governor             Actual Street Address                 City                 State ZIP+4 

Shareholder/Governor             Actual Street Address                 City                 State ZIP+4 

Shareholder/Governor             Actual Street Address                 City                 State ZIP+4 

6. Beneficial Interest (optional) - A beneficial owner is a person who has or in some manner controls an equity security.
Please consult an attorney for legal advice if you have any questions concerning this entry. Any question under this
heading is considered a request for legal advice and the Secretary of State’s office is, by statute, not permitted, to
provide legal advice.

Owner                            Description of Ownership                                   Percentage/Value 

Owner                            Description of Ownership                                   Percentage/Value 

No person may execute this report knowing it is false in any material respect.  Any violation may be subject to a civil and/or 
criminal penalty (SDCL 47-1A-129; 22-39-36). 

Dated 
                                                          Signature of an authorized person 

Email 
      (Optional)                                          Printed Name 

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                                                                                            Annualreportforeign Feb 2018