Secretary of the 
                                                                                                     OFFICE USE ONLY
           State of Connecticut
           PHONE: 860-509-6003 • EMAIL: crd@ct.gov • WEB: www.concord-sots.ct.gov

FOREIGN REGISTRATION STATEMENT                                                        •  Use ink.  •  Print or type. 
LIMITED LIABILITY COMPANY – FOREIGN                                                   •  Attach additional 8 1/2 x 11 sheets if necessary.

FILING PARTY  (Confirmation will be sent to this address):

NAME:
                                                                                                               FILING FEE: $120
MAILING 
ADDRESS:                                                                                                       Make checks payable to 
                                                                                                               “Secretary of the State”
CITY:
STATE:                                                       ZIP:                –

1.  NAME OF LIMITED LIABILITY COMPANY IN STATE OR COUNTRY OF FORMATION                               (required) 
 (Must include business designation such as LLC, L.L.C., etc.):

2.  ALTERNATE NAME TO BE USED IN CONNECTICUT                      (complete only if name at “1” is not available) 
 (Must include business designation such as LLC, L.L.C., etc.):

3. STATE / COUNTRY OF FORMATION            (required):                           4.  DATE OF FORMATION (required): 
                                                                                 ( mm / dd / yyyy )

5.  DATE LIMITED LIABILITY COMPANY BEGAN / WILL BEGIN 
 TRANSACTING BUSINESS IN CONNECTICUT                      (required): 
 ( mm / dd / yyyy )

6.  PRINCIPAL OFFICE ADDRESS AND MAILING ADDRESSES                               (required):
     PRINCIPAL OFFICE ADDRESS:                                                   PRINCIPAL OFFICE MAILING ADDRESS: 
 (P.O. Box unacceptable)
   STREET:                                                                       STREET OR P.O. BOX: 

   CITY:                                                                         CITY:

   STATE:                        ZIP:                  –                         STATE:                        ZIP:       –

7.  IF LLC IS REQUIRED TO MAINTAIN AN ADDRESS IN STATE / COUNTRY OF FORMATION, THEN COMPLETE BOTH:
     OFFICE ADDRESS IN STATE OF FORMATION:                                       MAILING ADDRESS IN STATE OF FORMATION: 
 (P.O. Box unacceptable)
   STREET:                                                                       STREET OR P.O. BOX: 

   CITY:                                                                         CITY:

    STATE:                       ZIP:                  –                         STATE:                        ZIP:       –

8.   ENTITY E-MAIL ADDRESS       (required):                                     9.   NAICS CODE   (six digits)
 ( Check box if none. Do not leave blank. )

    None

PAGE 1 OF 3                                                                                                                Rev. 03/2020

                   Secretary of the 
                                                                                                                OFFICE USE ONLY
                   State of Connecticut
                   PHONE: 860-509-6003 • EMAIL: crd@ct.gov • WEB: www.concord-sots.ct.gov

                              NOTE:  COMPLETE EITHER 10A OR 10B OR 10C BELOW – NOT ALL THREE.
10.   APPOINTMENT OF REGISTERED AGENT FOR SERVICE OF PROCESS                                     (required): 
  The LLC may not be appointed as its own Agent. However, the Manager / Member of the LLC residing in Connecticut 
  may be the Agent.  (Check A or complete B or C):

 A.          The Limited Liability Company appoints the Secretary of the State of Connecticut and his/her successors in office to be its 
               agent, upon whom any process, notice or demand may be served.

                           NOTE:  DO NOT COMPLETE 10B IF AGENT APPOINTED IN 10A ABOVE OR 10C BELOW.

 B.         If Agent is an individual,        print or type full legal name:  ___________________________________________________________

       Signature accepting appointment                ▸ __________________________________________________________________________

BUSINESS ADDRESS              (required):                Check box if none:             CONNECTICUT RESIDENCE ADDRESS        (required):
(P.O. Box unacceptable)                                                                  (P.O. Box unacceptable)
STREET:                                                                                  STREET:

CITY:                                                                                    CITY:
STATE:                                       ZIP:                    –                   STATE:  CT                 ZIP:             –
CONNECTICUT MAILING ADDRESS                     (required):
STREET OR P.O. BOX:

CITY:
STATE:                     CT                        ZIP:                          –

                              NOTE:  DO NOT COMPLETE 10C IF AGENT APPOINTED IN 10A OR 10B ABOVE.

 C.           If Agent is a business, 
               print or type name of business as it appears on our records:               ______________________________________________________

        Signature accepting appointment 
  on behalf of agent:                                 ▸  ________________________________________________________________________

       Print full name and title of person signing on behalf of agent:   ____________________________________________________
CONNECTICUT BUSINESS ADDRESS                          (required):                        CONNECTICUT MAILING ADDRESS          (required):
(P.O. Box unacceptable)
STREET:                                                                                  STREET OR P.O. BOX:

CITY:                                                                                    CITY:

STATE:         CT            ZIP:                                   –                    STATE:                 CT       ZIP:      –

PAGE 2 OF 3                                                                                                                              Rev. 03/2020

         Secretary of the 
                                                                                                 OFFICE USE ONLY
         State of Connecticut
         PHONE: 860-509-6003 • EMAIL: crd@ct.gov • WEB: www.concord-sots.ct.gov

11.   MANAGER OR MEMBER INFORMATION                     (required):
(Must list at least one Manager or Member of the LLC.)
         NAME                         TITLE             BUSINESS ADDRESS            (No PO Box)   RESIDENCE ADDRESS    (No PO Box)

                                                                   Check if none:   
                                                        ADDRESS:                                  ADDRESS:

                                                        CITY:                                     CITY:
                                                        STATE:                 ZIP:   –           STATE:          ZIP: –

                                                                   Check if none:   
                                                        ADDRESS:                                  ADDRESS:

                                                        CITY:                                     CITY:
                                                        STATE:                 ZIP:   –           STATE:          ZIP: –

                                                                   Check if none:   
                                                        ADDRESS:                                  ADDRESS:

                                                        CITY:                                     CITY:
                                                        STATE:                 ZIP:   –           STATE:          ZIP: –
12.   EXECUTION  (required – subject to penalty of false statement):
The undersigned asserts that the subject limited liability company is a foreign limited liability company.

 Date  ( mm / dd / yyyy:)   ______________________
     NAME OF SIGNATORY                                        CAPACITY / TITLE 
                                                                   OF SIGNATORY                               SIGNATURE

                                                                                                 ▸

                               Make checks payable to “The Secretary of the State.”

OFFICE OF THE SECRETARY OF THE STATE
Mailing Address:                                                               Delivery Address: 
Business Services Division                                                     Business Services Division 
Connecticut Secretary of the State                                             Connecticut Secretary of the State 
P.O. Box 150470                                                                165 Capitol Avenue, Suite 1000 
Hartford, CT 06115-0470                                                        Hartford, CT 06106
WEBSITE: www.concord-sots.ct.gov                                               PHONE: 860-509-6003

PAGE 3 OF 3                                                                                                            Rev. 03/2020

INSTRUCTIONS

1.    Provide the name of the limited liability company in its state of formation (name must include a business 
 designation such as L.L.C., LLC, etc.).
2.   If name provided in number 1 is not available for use in Connecticut, provide an alternate name that shall be 
 used in the state of Connecticut. The name must be distinguishable from all other business names on record 
 at the Office of the Secretary of State and must contain an appropriate limited liability company designation 
 such as LLC.
   To check availability of LLC name, go to www.sots.ct.gov; select Business Services; then under Business 
 Filings select “Search for a business” and type the name of your LLC. If the name comes up as active then 
 the name is not available.
3.    Provide the limited liability company's state or country of formation.
4.   Provide the date upon which the limited liability company was formed in its state or country of formation. The 
 date must include a month, day, and year.
5.   Provide the exact month, day, and year upon which the limited liability company began / will begin transacting 
 business in Connecticut. If the limited liability company has not yet commenced transacting business in 
 Connecticut, please make a statement to that effect (e.g., “upon filing” or “upon acceptance”).
6.    Provide the street number, street name, city, state and postal code for the principal office address. Note: The 
 principal office mailing address may include a P.O. Box.
7.    If the limited liability company is required to maintain an office in its state of formation, provide the street 
 address (must include a street number, street name), city, state, postal code, country (if other than the United 
 States) and a mailing address of the office (may include a P.O. Box).
8.    Provide the entity's email address (if none, check box “none”). The Secretary will notify entities via email 
 when their Annual Reports are due. Do not leave blank.
9.   NAICS CODE: (go to www.census.gov/naics ) 1-888-756-2427. (business / occupation / profession code)
10.   The limited liability company may appoint either:
 A.  The Secretary of the State
 or
 B.   An individual who is a resident of Connecticut, including a manager or member of the LLC. (An individual 
 must provide the complete street address of his or her business and a complete Connecticut residence 
 address and a Connecticut mailing address.
 or
 C.     Any of the following business types, on record with this office:
 •  A Connecticut corporation, limited liability company, limited liability partnership, or statutory trust.
 •  A foreign corporation, limited liability company, limited liability partnership, or statutory trust which 
   has obtained a certificate of authority to transact business in Connecticut and has a Connecticut 
   address on file with this office.
   The business must provide a Connecticut business address in Box 9C and a Connecticut mailing address. 
 Print the name and title under the signature of the individual signing acceptance on behalf of the 
 business agent.
11.    The limited liability company must list the name, title, residence, and business address of one manager or 
 member of the limited liability company. (Attach an extra sheet if additional space is required.)
12.    The document must be executed  /  signed by an authorized official of the limited liability company. That person 
 must print or type his  /  her full legal name, state the capacity  /  title under which he  /  she signs and provide his/
 her signature. The execution  /  signature constitutes a legal statement under the penalties of false statement 
 that the information provided in the document is true.
An annual report will be due yearly, to be filed between January 1st and March 31st, and can be easily filed 
online at www.concord-sots.ct.gov.

                                                                                                    Rev. 03/2020