Form Lc 51 - Limited Liability Company Annual Report - 2005
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1Contact Information
KANSAS SECRETARY OF STATE
LC
Kansas Secretary of State
Limited Liability Company Annual Report
Ron Thornburgh
50
Memorial Hall, 1st Floor
All information must be completed and the required fee submitted or this
120 S.W. 10th Avenue
document will not be accepted for filing. Please read all instructions
Topeka, KS 66612-1594
before completing this document.
(785) 296-4564
1. Business Entity ID Number: ________________________________
(This is not the FEIN)
2. LLC name: ______________________________________________
_________________________________________________________
3. Mailing address: _________________________________________
Address
Do not write in this space
_________________________________________________________
City
State
Zip
4. Tax closing date: _ __________________________________
5. State of organization: _____________________________
Month
Day
Year
6. Federal Employer ID Number (FEIN): _______________________________________
7. Members who own 5% or more of capital (Kansas limited liability companies only):
__________________________________________________________________________________________
Na m e
Address
City
State
Zip
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
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.
Executed on the ________ of ________________, _____________.
Day
Month
Year
Member's name (printed or typed)
Signature of member
Phone number
Rev. 11/01/05 nr
K.S.A. 17-76,139
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