Form Si-200 N/c - Statement Of Information (Domestic Stock And Agricultural Cooperative Corporations) - 2010
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1S
State of California
Secretary of State
Statement of Information
(Domestic Stock and Agricultural Cooperative Corporations)
FEES (Filing and Disclosure): $25.00. If amendment, see instructions.
IMPORTANT – READ INSTRUCTIONS BEFORE COMPLETING THIS FORM
1. CORPORATE NAME
This Space for Filing Use Only
Due Date:
[For forms preprinted by the Secretary of State.]
No Change Statement
(Not applicable if agent address of record is a P.O. Box address. See instructions.)
If there has been no change in any of the information contained in the last Statement of Information filed with the California Secretary of
2.
State, check the box and proceed to Item 16.
If there have been any changes to the information contained in the last Statement of Information filed with the California Secretary of State,
or no statement 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 3 and 4 cannot be P.O. Boxes.)
3.
STREET ADDRESS OF PRINCIPAL EXECUTIVE OFFICE
CITY
STATE
ZIP CODE
4.
STREET ADDRESS OF PRINCIPAL BUSINESS OFFICE IN CALIFORNIA, IF ANY
CITY
STATE
ZIP CODE
CA
5.
MAILING ADDRESS OF CORPORATION, IF DIFFERENT THAN ITEM 3
CITY
STATE
ZIP CODE
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.)
6.
CHIEF EXECUTIVE OFFICER/
ADDRESS
CITY
STATE
ZIP CODE
7.
SECRETARY
ADDRESS
CITY
STATE
ZIP CODE
8.
CHIEF FINANCIAL OFFICER/
ADDRESS
CITY
STATE
ZIP CODE
Names and Complete Addresses of All Directors, Including Directors Who are Also Officers
(The corporation must have at least one
director. Attach additional pages, if necessary.)
9.
NAME
ADDRESS
CITY
STATE
ZIP CODE
10. NAME
ADDRESS
CITY
STATE
ZIP CODE
11. NAME
ADDRESS
CITY
STATE
ZIP CODE
12. NUMBER OF VACANCIES ON THE BOARD OF DIRECTORS, IF ANY:
Agent for Service of Process (
If the agent is an individual, the agent must reside in California and Item 14 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 14 must be left blank.)
13. NAME OF AGENT FOR SERVICE OF PROCESS
[Note: The person designated as the corporation's agent MUST have agreed to act in that capacity prior to the designation.]
14.
CITY
STATE
ZIP CODE
STREET ADDRESS OF AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL
CA
Type of Business
15. DESCRIBE THE TYPE OF BUSINESS OF THE CORPORATION
16. BY SUBMITTING THIS STATEMENT OF INFORMATION TO THE CALIFORNIA SECRETARY OF STATE, THE CORPORATION CERTIFIES THE INFORMATION
CONTAINED HEREIN, INCLUDING ANY ATTACHMENTS, IS TRUE AND CORRECT.
DATE
TYPE/PRINT NAME OF PERSON COMPLETING FORM
TITLE
SIGNATURE
SI-200 N/C (REV 10/2010)
APPROVED BY SECRETARY OF STATE
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