Fill and Sign the All Required Sections Must Be Completed Note This Form Can

INSTRUCT IONS All require d sections must be completed. Note: th is fo rm can be filed online a t www.concord-sots.ct.gov . 1. Na m e of Lim i ted Liab ility Com pany: T he nam e MUST INCLUDE a business de signat ion, such as Lim i ted Liabi lity Co mpany, LLC, L.L.C ., Lim i ted Liab ilit y Co ., Ltd. Liability Com pany, or Ltd. Liab ilit y Co. Profe ssional LLCs m ust c ontain P. L.L.C ., PLLC, Profe ssion al Lim i ted Liabi lit y Com pany. Lim i ted m ay be abbreviat ed "Ltd" and Com pany m ay be abb reviat ed "Co" a nd th e nam e m ust be distinguishable from all other act ive bu siness names on record with this office. 2. P rincip al O ffic e: Include street num ber, street nam e, city, state a nd zi p cod e. NO P .O. B OX . 3. Mailing A ddress: Includ e street number, street name, city, sta te and zip co de. P.O. BOX is accep table. 4. Appoi ntm ent of regis tered agen t: T HE LIM IT ED LIABILIT Y COM PA NY M AY NOT BE IT S OW N AGENT . An ind ividual or busi ness entit y (other th an this LLC) m ust be appointed to acc ept legal process , notice or dem and served upon t he lim i ted liabi lit y com pany. The agent m ay be EIT HE R: a. An y indi vidual w ho is a resident of C onnectic ut, including a member or manag er of the LLC.  An indi vidua l m ust provide t he com pl ete street address of his or her busi ness, a Connectic ut resi dence address and a Con nectic ut m a iling addr ess. ( If no busi ness address, m ust state none).  T he agent m ust si gn accep ting the appointm ent. OR b. One of the following busi ness types, on record wi th this offic e, wi th a C onnect icut address:  A Con necticut cor porati on, lim i ted liabi lit y com pany, lim ited li abi lit y partne rship or statutory trus t.  A forei gn corporati on, li m ited liabilit y com pany, lim ited liab ilit y part ners hip or sta tu to ry trus t, wh ich has obtain ed a certific ate of autho rity to transact business in Connecticut and has a Connectic ut address o n file with this offic e.  Pro vide the Connectic ut princip al office address at "B usi ness address" and the Co nnecticut m a iling address at “m a iling addres s”. T he age nt m ust si gn accepting th e appoi ntm ent and the person si gning on behalf of a business m ust print his/h er nam e and title next to his/her signature.  T he agent m ust si gn accepti ng the a ppointm ent. 5. Me mber or m anager information : The lim i ted liability com pany m ust list the nam e, titl e, bu siness and residenc e addr ess of at least one m em ber or m anager of the lim i ted li ab ilit y com pany (if no business address, m ust s tate none). Include street num ber, s treet nam e, city, s tate and zi p code and check the appropriate box under “TITLE”. (Additi onal m ember(s) and m anage r(s) inform ation m ay be included on an attach ed 8 ½ x 11 sheet .) Note: LLCs m ay have as m any members/managers as th ey wis h. However, only three will be displayed on the CONCORD busines s inquiry page . Additio nal names will be availab le by requesting copies of the origi nal filing. 6. Em ail Ad dress: If none, m ust s tate "NONE". T he Secretar y of the State will notif y entities vi a em ail wh en th eir Annual Re ports are due. 7. Executio n: The or ganiz er (pers on form i ng the LLC) m ust print or t ype his/ her full nam e and pr ovi de a si gn atu re. Note that t he exec ution is made under the penalti es of false statem ent, certif yi ng that the inform ation pro vide d in the docum ent is true. If the organizer is another business entity, the person signing on behalf of the business entity must provide his/her full name and title for the organizing entity. THE LIMITED LIABILITY COMPANY ITSELF MAY NOT BE ITS OWN ORGANIZER, BUT A MEMBER/MANAGER OF THE LLC MAY BE THE ORGANIZER. *** YO U ARE REQUIRED T O FILE A CERTIFIC AT E OF DISSOLUTION IF YOU DI SS OLVE YO UR BUSIN ESS. *** INSTRUCTIONS DO NOT SCAN Rev. 4/2018 SECRETARY OF THE STATE OF CONNECTIC UT MAILI NG ADDRESS: BUSINES S SERVICES DIVISION, CONNECTICUT SE CRETARY OF THE STATE, P .O. BOX 150470, H ARTFORD, CT 061 15-0470 DELIVERY A DDRESS: BUSINESS SERVICES DIVISION, CONNECTICUT SECRETARY OF THE STATE, 30 TRINITY STR EET, HARTFORD, CT 06106 PHONE: 860-509- 6003 WEBSIT E : www.c oncord-so ts.ct. gov CERTIFICATE OF ORGANIZA TION FILING FEE: $1 20 LIMIT ED LIABILITY COMPANY – DOM ESTIC MAKE CHECKS PAYABLE TO “ SECRETARY OF T HE STATE” C.G.S . §34- 247 USE INK . COMPLETE ALL SECTIONS. PRINT OR TY PE. ATTACH 8 1/2 X 11 SHEETS IF NECES SARY. FILING PARTY (CONFIRMATION WILL BE SE NT TO THIS ADD RESS ): NAME: MAILING AD DRESS: CITY: STATE: ZIP: 1. N AM E OF LIM ITED LIABILITY COM PA NY - REQ UIRE D: (MUST INCLUDE BUSINESS DESIGNATION I.E. L.L.C., LLC) 2. PRIN CIPAL O FFICE ADDRESS - REQUIRED (NO P.O. BOX) - P ROVIDE FULL ADDR ESS STRE ET: CITY: STATE: ZIP: 3. M AILING ADDR ESS - REQ UIRED PROVIDE F ULL ADDR ESS. - P.O. B OX IS ACC EPTAB LE STRE ET OR P. O. BOX: CITY: STATE: ZIP: 4. APPOINTMENT OF REGISTERED AGENT - REQUIRED (COMPLETE A OR B NOT BOTH) A. IF AGENT IS AN INDIVIDU AL: x PRINT OR TYPE NAME SIGNATURE ACCEPTING APPO INTMENT: BUSINESS ADD RES S - REQUIRED (P. O. BOX NOT A CCEPT ABLE) IF NONE, MUST CHECK "NONE" CONNECTICUT RESIDEN CE ADDRESS - REQUIRED (P. O. BOX NOT A CCEPTABLE) CHECK IF NONE ST RE ET: CIT Y: STATE : ZIP: ZIP: STRE ET: CIT Y: STATE: ZIP: CONNECTICUT M AILING ADDR ESS - REQUIRE D: (P. O.B OX ACCEPTABLE) STRE ET OR P.O. BOX: CITY: STATE: ZIP: PAGE 1 OF 2 Rev. 4 /2018 Not e: DO NOT COMPLETE 4B IF AGENT APPOINTED IN 4A. B. IF AGENT IS A BU SIN ESS: _______________________________________________________________________________________ PRINT OR TYPE NAME OF BUSINESS AS IT APPEARS ON OUR RECORDS X______________________________________________________________________________________ SIGNATURE ACCEPTING APPOINTMENT ON BEHALF OF AGENT _______________________________________________________________________________________ PRINT NAME & TITLE OF PERSON SIGNING ON BEHALF OF AGENT CONNECTICUT BUSINESS ADDR ESS - REQUIRED (P.O . BOX UNA CCEPTABLE) CONNECTICUT M AILI NG ADDRESS - REQUIRED (P.O. BOX ACCEPTABLE) STRE ET: CITY: STATE: ZIP: STREET OR P.O. BOX: CITY: STATE: ZIP: 5. MANAGER OR MEMBER INF OR MATION - REQUIRED (MUST LIST AT LEAST ONE MEMBER OR MANAGER OF THE LLC) (ATTACH 8 ½ X 11 SHEETS IF NECESSARY) FULL NAME TITLE BUSINESS ADDRESS (NO P .O. BOX) RESIDENCE ADDRESS (NO P. O. BOX) MEMBER MANAGER CHECK IF NONE MEMBER MANAGER CHECK IF NONE 6. ENTITY EMAIL ADDRE SS - REQUIRED: (IF NONE, MUST STATE “NONE”) DO NOT LEA VE BL ANK ____________________________________________________________________________________ 7. EXECU TION - REQUIRED : (SUBJE CT TO PENALTY OF FALSE STATEMENT) DATE (MM /DD /YYY Y) ___________________________ NAME OF ORGANIZER (PRINT/TYPE) (THE LLC CANNOT BE ITS OWN ORGANIZER) SIGNATURE X_____________________________________________ AN ANNUAL REPORT WILL BE DUE YEARLY IN THE FOLLOWING YEAR THAT THE ENTITY W AS FORMED/REGISTERED BETWEEN JANUARY 1ST AND MARCH 31ST AND CAN BE EASILY FILED ONLINE @ WWW.CONCORD -SOTS.CT.GOV. CONTACT YOUR TAX ADVISOR OR THE TAXPAYER SERVICE CENTER AT THE DEPARTMENT OF REVENUE SERVICES AS TO ANY POTENTIAL TAX LIABILITY RELATIN G TO YOUR BUSINESS, INCLUDING QUESTIONS ABOUT THE BUSINESS ENTITY TAX. TAX PAYER SERVICE CENTER: (860) 297-5962 OR @ WWW.CT.GOV/DRS. PAGE 2 OF 2 Rev. 4 /2018