Statement Of Correction Information For Historical Purposes
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1
2Form must be filed electronically.
Paper forms are not accepted.
This copy is a sample and cannot be submitted for filing.
Statement of Correction
Correcting Information for Historical Purposes
filed pursuant to § 7-90-305 of the Colorado Revised Statutes (C.R.S.)
1. The entity ID number and the entity name, or, if the entity does not have an entity name, the true name are
Entity ID number
__________________________
(Colorado Secretary of State ID number)
Entity name or True name
______________________________________________________.
2. The document number of the filed document that is corrected is ___________________________________.
3.
(The following statement is adopted by marking the box.)
The information contained in the filed document identified above that is incorrect is identified in the
attachment and such information, as corrected, is stated in the attachment.
4.
(If applicable, adopt the following statement by marking the box and include an attachment.)
This document contains additional information as provided by law.
Notice:
Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or
acknowledgment of each individual causing such delivery, under penalties of perjury, that such document is
such individual's act and deed, or that such individual in good faith believes such document is the act and deed
of the person on whose behalf such individual is causing such document to be delivered for filing, taken in
conformity with the requirements of part 3 of article 90 of title 7, C.R.S. and, if applicable, the constituent
documents and the organic statutes, and that such individual in good faith believes the facts stated in such
document are true and such document complies with the requirements of that Part, the constituent documents,
and the organic statutes.
This perjury notice applies to each individual who causes this document to be delivered to the Secretary of
State, whether or not such individual is identified in this document as one who has caused it to be delivered.
5. The true name and mailing address of the individual causing this document to be delivered for filing are
____________________ ______________ ______________ _____
(Last)
(First)
(Middle)
(Suffix)
______________________________________________________
(Street number and name or Post Office Box information)
______________________________________________________
_
_
__
__________________________
____________________
(City)
(State)
(ZIP/Postal Code)
_______________________ ______________.
(Province – if applicable)
(Country)
(If applicable, adopt the following statement by marking the box and include an attachment.)
This document contains the true name and mailing address of one or more additional individuals
causing the document to be delivered for filing.
CORRECT_HIST
Page 1 of 2
Rev. 10/07/2008
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