Form Lc 50 - Limited Liability Company Annual Report - 2016 Page 2
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kansas secretary of state
LC
Limited Liability Company
Please complete the form, print, sign and mail to the
Annual Report
50
Kansas Secretary of State with the filing fee. Selecting
'Print' will print the form and 'Reset' will clear the entire
form.
Kansas Office of the Secretary of State:
Memorial Hall, 1st Floor
(785) 296-4564
120 S.W. 10th Avenue
kssos@sos.ks.gov
Topeka, KS 66612-1594
THIS SPACE FOR OFFICE USE ONLY.
1.
Business entity ID #
This is not the Federal Employer ID
Number (FEIN).
2.
LLC name
Must match name on record with
Kansas Secretary of State.
Attention Name
Address
3.
Mailing address
Address will be used to
send official mail from the
City
State
Zip
Country
Secretary of State’s Office.
Do not leave blank.
o
Check this box if this is a new address. Our records will be updated only if this box is checked.
Month
Year
4.
Tax closing date
5.
State of organization
Name
Address
6.
Name and address
of each member who
owns 5% or more of
City
State
Zip
Country
capital (Kansas LLC
only)
Name
Address
If additional space is needed,
please provide attachment.
City
State
Zip
Country
Name
Address
City
State
Zip
Country
7.
Federal Employer Identification Number (FEIN)
8.
I declare under penalty of perjury pursuant to the laws of the state of Kansas that the foregoing is true and
correct and that I have remitted the required fee.
Signature of Member
X
Name of Signer (printed or typed)
Phone Number
1 / 1
Please review to ensure completion.
K.S.A. 17-76,139
Rev. 6/30/16 tc
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