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Charlie Daniels, Arkansas Secretary of State

ANNUAL CORPORATION FRANCHISE TAX REPORT 2009

(Non-Stock Corporation)

For the year ending 12/31/2008

Reports and Taxes are due on or before May 1, 2009. Penalty and Interest will be due for reports if the United States Postal Service’s

postmark is after the deadline. Complete this report online at or sign in ink and mail to the address

listed below.

*123456789*

Correct any information, if needed, in space provided below

Tax contact name: ____________________________________

Save time, file online at anytime

Address: ____________________________________________

day or night at

Address Line 2: _______________________________________

City, State, Zip: _______________________________________

Phone # of tax contact: _________________________________

Date of Qualification: ________________________________

E-mail address: _______________________________________

State of Incorporation: _______________________________

Required Information

Nature of Business: _________________________________

Federal Tax ID# ______________________________________

Registered Agent Information:

___A

4, 5 & 6

LL OF THE INFORMATION IN SECTION

HAS

Name: ______________________________________

BEEN VERIFIED AND HAS BEEN FOUND TO BE EXACTLY THE

____

SAME AS LAST YEARS REPORT

Address 1: _______________________________________

Address 2: _______________________________________

Current names of corporate governors:

City, State, Zip: ___________________________________

President: ______________________________________

Principal Office Information:

Vice-President: __________________________________

Address: ________________________________________

Secretary: ______________________________________

City, State Zip: ___________________________________

Treasurer: ______________________________________

Controller:

____________________________________________

Tax Preparer:

_________________________________________

$300.00: T

$300.00

ORPORATIONS

ITHOUT

UTHORIZED

TOCK

OTAL

I declare, under the penalties of perjury, that the foregoing statements are true to the best of my knowledge and belief.

Signature________________________________________ Executed this _________ day of __________________, ____________

An officer or tax preparer listed in 4 above must sign this form in ink

(Day)

(Month)

(Year)

Due on or before May 1, 2009 – Penalty and Interest due after May 1, 2009

You may file this electronically over the Internet @

Remittance must accompany this report • Make Checks Payable to Arkansas Secretary of State

Phone 501-682-3409 or 1-888-233-0325

Mail to: Business and Commercial Services Division • P.O. Box 8014 • Little Rock, Arkansas 72203-8014

Annual Corporation Franchise Tax Report (Non-Stock Corporation) - Arkansas Secretary Of State - 2009

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