Form Si-100 - Statement Of Information (Domestic Nonprofit, Credit Union And Consumer Cooperative Corporations)

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State of California

Secretary of State

Statement of Information

(Domestic Nonprofit, Credit Union and Consumer Cooperative Corporations)

Filing Fee: $20.00. 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

Complete Principal Office Address

(Do not abbreviate the name of the city. Item 3 cannot be a P.O. Box.)

STREET ADDRESS OF PRINCIPAL OFFICE IN CALIFORNIA, IF ANY

C ITY

STATE

ZIP CODE

MAILING ADDRESS OF THE CORPORATION

ITY

STATE

ZIP CODE

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.)

CHIEF EXECUTIVE OFFICER/

ADDRESS

ITY

STATE

ZIP CODE

SECRETARY

ADDRESS

CITY

STATE

ZIP CODE

CHIEF FINANCIAL OFFICER/

ADDRESS

ITY

STATE

ZIP CODE

Agent for Service of Process

If the agent is an individual, the agent must reside in California and Item 9 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 9 must be left blank.

[Note: The person designated as the corporation's agent MUST have agreed to act in that capacity prior to the designation.]

NAME OF AGENT FOR SERVICE OF PROCESS

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

CITY

STATE

ZIP CODE

Common Interest Developments

10.

Check here if the corporation is an association formed to manage a common interest development under the Davis-Stirling Common Interest

Development Act, (California Civil Code section 4000, et seq.) or under the Commercial and Industrial Common Interest Development Act,

(California Civil Code section 6500, et seq.). The corporation must file a Statement by Common Interest Development Association (Form SI-CID) as