Fill and Sign the M895 Insurance Form

INSTRUCTIONS FOR COMPLETING FORM LLC-12R For easier completion, this form is available on the Secretary of State's website at http://www.sos.ca.gov/business/ and can be viewed, filled in and printed from your computer. 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 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 should not be altered. Every domestic and registered foreign limited liability company shall file a Statement of Information with the Secretary of State, within 90 days after filing of its original Articles of Organization or Application for Registration, and biennially thereafter during the applicable filing period. The applicable filing period for a limited liability company is the calendar month during which its original Articles of Organization or Application for Registration were filed and the immediately preceding five calendar months. A limited liability company 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. Statutory filing provisions are found in California Corporations Code section 17060, unless otherwise indicated. Failure to file this Statement of Information by the due date will result in the assessment of a $250.00 penalty. (Corporations Code sections 17651(b) and 17653; Revenue and Taxation Code section 19141.) FILING FEES: The fee for filing the initial or biennial Statement of Information is $20.00. Checks should be made payable to the Secretary of State. 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: The Secretary of State will endorse file one copy of the statement if an exact copy is submitted along with the statement to be filed. Copies submitted with the statement to be filed can be certified upon request and payment of the $8.00 per copy certification fee. Complete the Statement of Information (Form LLC-12R) as follows: Item 1. Please do not alter the preprinted name. If the name is not correct, please attach a statement indicating the correct name and the date the name change amendment was filed with the Secretary of State. If blank, enter the name of the limited liability company exactly as it is of record with the California Secretary of State. Item 2. Please do not alter the preprinted file number. If blank, enter the file number issued by the California Secretary of State. Item 3. Please do not alter the preprinted jurisdiction. If blank, and the limited liability company is a registered foreign limited liability company (organized outside the state of California), enter the state or place under the laws of which the limited liability company is organized. No If there has been any change to the last Statement of Information filed with the Secretary of State, including a change to any Change address, or no Statement of Information has ever been filed, complete this form in its entirety. If there has been no change in the information contained in the last Statement of Information filed with the Secretary of State, check the box and proceed to Item 13. Item 4. Enter the complete street address, city and zip code of the limited liability company’s principal executive office. Please do not enter a P.O. Box or abbreviate the name of the city. This address will be used for mailing purposes. Item 5. If the limited liability company is formed under the laws of the state of California, enter the complete street address, city and zip code of the office required to be maintained pursuant to Corporations Code section 17057(a). Please do not enter a P.O. Box or abbreviate the name of the city. Item 6. Enter the name and complete business or residential address of the chief executive officer, if any. Please do not abbreviate the name of the city. Items 7-9. Enter the name and complete business or residential address of any manager or managers, appointed or elected in accordance with the Articles of Organization or Operating Agreement, or if no manager has been so elected or appointed, the name and business or residential address of each member. Attach additional pages, if necessary. Please do not abbreviate the name of the city. Item 10. Enter the name of the agent for service of process in California. An agent is an individual (manager, member or any other person, whether or not affiliated with the company) who resides in California or a corporation designated to accept service of process if the company is sued. The agent must agree to accept service of process on behalf of the company prior to designation. If a corporation is designated as agent, that corporation must have previously filed with the Secretary of State, a certificate pursuant to Corporations Code section 1505. Note, a limited liability company cannot act as its own agent and no domestic or foreign corporation may file pursuant to section 1505 unless the corporation is currently authorized to engage in business in California and is in good standing on the records of the Secretary of State. If an individual is designated as agent, complete Items 10 and 11. If a corporation is designated as agent, complete Item 10 and proceed to Item 12 (do not complete Item 11). Item 11. If an individual is designated as agent for service of process, enter a business or residential address in California. Please do not enter “in care of” (c/o) or abbreviate the name of the city. Please do not enter an address if a corporation is designated as agent. Item 12. Briefly describe the general type of business that constitutes the principal business activity of the limited liability company. Item 13. Type or print the name and title of the person completing this form and enter the date this form was completed. L State of California Secretary of State STATEMENT OF INFORMATION (Limited Liability Company) Filing Fee $20.00. If amendment, see instructions. IMPORTANT — READ INSTRUCTIONS BEFORE COMPLETING THIS FORM 1. LIMITED LIABILITY COMPANY NAME (Please do not alter if name is preprinted.) This Space For Filing Use Only DUE DATE: [For forms preprinted by the Secretary of State.] FILE NUMBER AND STATE OR PLACE OF ORGANIZATION 2. SECRETARY OF STATE FILE NUMBER 3. STATE OR PLACE OF ORGANIZATION NO CHANGE STATEMENT If there has been no change in any of the information contained in the last Statement of Information filed with the Secretary of State, check the box and proceed to Item 13. If there have been any changes to the information contained in the last Statement of Information filed, or no Statement of Information has been previously filed, this form must be completed in its entirety. 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 AND STATE 5. CALIFORNIA OFFICE WHERE RECORDS ARE MAINTAINED (DOMESTIC ONLY) ZIP CODE CITY STATE ZIP CODE CA NAME AND COMPLETE ADDRESS OF THE CHIEF EXECUTIVE OFFICER, IF ANY 6. NAME ADDRESS CITY AND STATE ZIP CODE NAME AND COMPLETE ADDRESS OF ANY MANAGER OR MANAGERS, OR IF NONE HAVE BEEN APPOINTED OR ELECTED, PROVIDE THE NAME AND ADDRESS OF EACH MEMBER (Attach additional pages, if necessary.) 7. NAME ADDRESS CITY AND STATE ZIP CODE 8. NAME ADDRESS CITY AND STATE ZIP CODE 9. NAME ADDRESS CITY AND STATE ZIP CODE AGENT FOR SERVICE OF PROCESS (If the agent is an individual, the agent must reside in California and Item 11 must be completed with a California address. If the agent is a corporation, the agent must have on file with the California Secretary of State a certificate pursuant to Corporations Code section 1505 and Item 11 must be left blank.) 10. NAME OF AGENT FOR SERVICE OF PROCESS 11. ADDRESS OF AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL CITY STATE ZIP CODE CA TYPE OF BUSINESS 12. DESCRIBE THE TYPE OF BUSINESS OF THE LIMITED LIABILITY COMPANY 13. THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT. TYPE OR PRINT NAME OF PERSON COMPLETING THE FORM SIGNATURE TITLE LLC-12R (REV 03/2007) DATE APPROVED BY SECRETARY OF STATE Clear Form Print Form