Secretary of State Office 
500 E Capitol Ave                                        ANNUAL REPORT 
Pierre, SD  57501                      DOMESTIC 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         South Dakota 

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 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 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                            Address                            City                 State ZIP+4 

Owner                            Address                            City                 State ZIP+4 

Owner                            Address                            City                 State ZIP+4 

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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                                                                                          Annualreportdomestic  Feb 2018