Enter Filing Year                          ANNUAL REPORT 
Secretary of State Office              DOMESTIC NONPROFIT  ORPORATIONC                
500 E Capitol Ave                                        SDCL 47-24-6, 59-11-24 
Pierre, SD 57501 
(605)773-4845
corpinfo@state.sd.us                                     FILING FEE:  
                                       $10 Make check payable to SECRETARY OF STATE

1. Business ID and Name:

   Business ID

   Business Name
2. The jurisdiction under whose law it is formed           SouthDakota 

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) 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 business

   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 addresses of its principal officers and directors (governors). South Dakota Law requires at least three
directors.

Principal Officer/Director/Governor Actual Street Address                 City                 State ZIP+4 

Principal Officer/Director/Governor Actual Street Address                 City                 State ZIP+4 

Principal Officer/Director/Governor Actual Street Address                 City                 State ZIP+4 

Principal Officer/Director/Governor Actual Street Address                 City                 State ZIP+4 

6.Beneficial Interest (optional)

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 22-39-36). 

Dated 
                                                             Signature of an authorized person 

Email 
      (Optional)                                             Printed Name 

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                                                                               annualreportdomesticnonprofit Feb 2018