Si 200 Form – Fill Out and Use

Instructions For Completing Form SI-200

For faster processing, the required statement for most corporations can be filed online at https://businessfilings.sos.ca.gov.

Every domestic stock and agricultural cooperative corporation must file a Statement of Information with the California Secretary of State, within 90 days after the filing of its initial Articles of Incorporation, and annually thereafter during the applicable filing period. The applicable filing period for a domestic corporation is the calendar month during which the initial Articles of Incorporation were filed and the immediately preceding five calendar months. A corporation is required to file this statement even though it may not be actively engaged in business at the time this statement is due. Changes to information contained in a previously filed statement can be made by filing a new form, completed in its entirety.

Legal Authority: Statutory filing provisions are found in California Corporations Code section 1502 or California Food and Agricultural Code section 54040, unless otherwise indicated. All subsequent statutory references are to the California Corporations Code, unless otherwise stated. Failure to file this Statement of Information by the due date will result in the assessment of a $250.00 penalty. (Section 2204; California Revenue and Taxation Code section 19141.)

Fees: The Statement of Information must be accompanied by a $20.00 filing fee and $5.00 disclosure fee. The filing fee and the disclosure fee may be included in a single check made payable to the Secretary of State. All domestic stock and agricultural cooperative corporations must pay a total of $25.00 at the time of filing the statement. If this statement is being filed to amend any information on a previously filed statement and is being filed outside the applicable filing period, as defined above, no fee is required.

Copies: To get a copy of the filed statement, include a separate request and payment for copy fees when the statement is submitted. Copy fees are $1.00 for the first page and $.50 for each additional page. For certified copies, there is an additional $5.00 certification fee, per copy.

Publicly Traded Corporations: Every publicly traded corporation also must file a Corporate Disclosure Statement (Form SI-PT) annually, within 150 days after the end of its fiscal year. A “publicly traded corporation” is a corporation, as defined in Section 162, that is an issuer as defined in Section 3 of the Securities Exchange Act of 1934, as amended (United States Code, Title 15, section 78c), and has at least one class of securities listed or admitted for trading on a national securities exchange, on the OTC-Bulletin Board, or on the electronic service operated by Pink OTC Markets Inc. Form SI-PT may be obtained from the Secretary of State’s website at www.sos.ca.gov/business/be/statements.htm or by calling the Statement of Information Unit at (916) 657-5448.

Complete the Statement of Information (Form SI-200) as follows:

Item 1. Enter the name of the corporation exactly as it is of record with the California Secretary of State.

Item 2.

Item 3.

Item 4.

Item 5.

Item 6.

Items 7-9.

Items 10-12.

Item 13.

Item 14.

Item 15.

Item 16.

Item 17.

Completed forms along with the applicable fees can be mailed to Secretary of State, Statement of Information Unit, P.O. Box 944230, Sacramento, CA 94244-2300 or delivered in person (drop off) to the Sacramento office, 1500 11th Street, Sacramento, CA 95814. If you are not completing this form online, please type or legibly print in black or blue ink. This form must not be altered. This form is filed only in the Sacramento office.

State of California	S
Secretary of State

Statement of Information

(Domestic Stock and Agricultural Cooperative Corporations)

FEES (Filing and Disclosure): $25.00.

If this is an amendment, see instructions.

IMPORTANT – READ INSTRUCTIONS BEFORE COMPLETING THIS FORM

1.CORPORATE NAME

2.CALIFORNIA CORPORATE NUMBER

This Space for Filing Use Only

No Change Statement (Not applicable if agent address of record is a P.O. Box address. See instructions.)

3.If there have been any changes to the information contained in the last Statement of Information filed with the California Secretary of State, or no statement of information has been previously filed, this form must be completed in its entirety.

If there has been no change in any of the information contained in the last Statement of Information filed with the California Secretary of State, check the box and proceed to Item 17.

Complete Addresses for the Following (Do not abbreviate the name of the city. Items 4 and 5 cannot be P.O. Boxes.)

4.	STREET ADDRESS OF PRINCIPAL EXECUTIVE OFFICE	CITY	STATE	ZIP CODE
5.	STREET ADDRESS OF PRINCIPAL BUSINESS OFFICE IN CALIFORNIA, IF ANY	CITY	STATE	ZIP CODE
			CA
6.	MAILING ADDRESS OF CORPORATION, IF DIFFERENT THAN ITEM 4	CITY	STATE	ZIP CODE

7.EMAIL ADDRESS FOR RECEIVING STATUTORY NOTIFICATIONS

Names and Complete Addresses of the Following Officers (The corporation must list these three officers. A comparable title for the specific officer may be added; however, the preprinted titles on this form must not be altered.)

7.	CHIEF EXECUTIVE OFFICER/	ADDRESS	CITY	STATE	ZIP CODE
8.	SECRETARY	ADDRESS	CITY	STATE	ZIP CODE
9.	CHIEF FINANCIAL OFFICER/	ADDRESS	CITY	STATE	ZIP CODE

Names and Complete Addresses of All Directors, Including Directors Who are Also Officers (The corporation must have at least one director. Attach additional pages, if necessary.)

10.	NAME	ADDRESS	CITY	STATE	ZIP CODE
11.	NAME	ADDRESS	CITY	STATE	ZIP CODE
12.	NAME	ADDRESS	CITY	STATE	ZIP CODE

13. NUMBER OF VACANCIES ON THE BOARD OF DIRECTORS, IF ANY:

Agent for Service of Process If the agent is an individual, the agent must reside in California and Item 15 must be completed with a California street address, a P.O. Box address is not acceptable. If the agent is another corporation, the agent must have on file with the California Secretary of State a certificate pursuant to California Corporations Code section 1505 and Item 15 must be left blank.

14. NAME OF AGENT FOR SERVICE OF PROCESS

15. STREET ADDRESS OF AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL CITY

STATE

ZIP CODE

CA

Type of Business

16.DESCRIBE THE TYPE OF BUSINESS OF THE CORPORATION

17.BY SUBMITTING THIS STATEMENT OF INFORMATION TO THE CALIFORNIA SECRETARY OF STATE, THE CORPORATION CERTIFIES THE INFORMATION CONTAINED HEREIN, INCLUDING ANY ATTACHMENTS, IS TRUE AND CORRECT.

DATE	TYPE/PRINT NAME OF PERSON COMPLETING FORM	TITLE	SIGNATURE
SI-200 (REV 01/2013)			APPROVED BY SECRETARY OF STATE