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Statement by Domestic Nonprofit Corporation (California)

This is a statement by a domestic nonprofit corporation in California. The form provided here is simply a sample of what the actual form looks like.

State of California
Bill Jones
Secretary of State

STATEMENT BY DOMESTIC NONPROFIT CORPORATION

1. CORPORATE NUMBER: ______________________________

CORPORATE NAME: ______________________________

2. STREET ADDRESS OF PRINCIPAL EXECUTIVE OFFICE IN CALIFORNIA, IF ANY

______________________________

CITY ____________________________

STATE ____________________________

ZIP CODE ____________________________

(If none, complete 3)

3. MAILING ADDRESS ______________________________

CITY ____________________________

STATE ____________________________

ZIP CODE ____________________________

LIST THE NAMES AND COMPLETE ADDRESSES OF THE OFFICERS: (The corporation must have these three officers. An officer may hold more than one office. The appropriate title for the officer may be added but do not alter or obliterate the form).

4. CHIEF EXECUTIVE OFFICER ______________________________

ADDRESS ______________________________

CITY ____________________________

STATE ____________________________

ZIP CODE ____________________________

5. SECRETARY______________________________

ADDRESS ______________________________

CITY ____________________________

STATE ____________________________

ZIP CODE ____________________________

6. CHIEF FINANCIAL OFFICER______________________________

ADDRESS ______________________________

CITY ____________________________

STATE ____________________________

ZIP CODE ____________________________

7. CHECK THE APPROPRIATE PROVISION BELOW AND NAME THE AGENT FOR SERVICE OF PROCESS:

[____] AN INDIVIDUAL RESIDING IN CALIFORNIA.

[____] A CORPORATION WHICH HAS FILED A CERTIFICATE PURSUANT TO SECTION 1505 OF THE CALIFORNIA CORPORATIONS CODE.

AGENT'S NAME: ______________________________

8. ADDRESS OF THE AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL

______________________________

CITY ____________________________

STATE CA

ZIP CODE ____________________________

9. ____ THIS CORPORATION IS NOT AN ASSOCIATION FORMED TO MANAGE A COMMON INTEREST DEVELOPMENT (PROCEED TO ITEM 11)

10. ____ THIS CORPORATION IS AN ASSOCIATION FORMED TO MANAGE A COMMON INTEREST DEVELOPMENT UNDER THE DAVIS-STIRLING COMMON INTEREST DEVELOPMENT ACT. (PROCEED TO ITEM 10A AND 10B)

10A. BUSINESS OFFICE STREET ADDRESS OR PHYSICAL LOCATION OF DEVELOPMENT, INCLUDING NINE-DIGIT ZIP CODE

______________________________

CITY ____________________________

STATE ____________________________

ZIP CODE ____________________________

10B. NAME AND ADDRESS OF THE MANAGING AGENT ______________________________

ADDRESS ______________________________

NAME ______________________________

ADDRESS ______________________________

CITY ____________________________

STATE ____________________________

ZIP CODE ____________________________

11. I DECLARE THAT I HAVE EXAMINED THIS STATEMENT AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS TRUE, CORRECT AND COMPLETE.

TYPE OR PRINT NAME OF SIGNING OFFICER OR AGENT

______________________________

ORIGINAL SIGNATURE ______________________________

TITLE ______________________________

DATE ______________________________


NOTES

Statutory filing provisions are found in Section 6210, 8210 and 9660 of the California Corporations Code, unless otherwise indicated.

Every domestic nonprofit corporation shall file a statement with the California Secretary of State, within 90 days after filing of its original Articles of Incorporation and (beginning January 1, 2000), biennially during the applicable filing period. The applicable filing period for a nonprofit domestic corporation shall be the end of the calendar month during which its original Articles of Incorporation were filed and the immediately preceding five calendar months. Domestic nonprofit corporations that have, or will be organized by filing Articles of Incorporation during the months of January, March, May, July, September and November will be due to file in odd years and those organized in the months of February, April, June, August, October and December will be due to file in even years.

If this is the initial statement or a biennial statement attach the fee of $20. If this filing is a change to any information on an initial statement or a biennial statement there is no fee.

A domestic nonprofit corporation is required to file a statement even though it may not be actively engaged in business at the time this statement is due.

Failure to file this completed form by the preprinted due date in Item 1 or within 90 days of incorporation will result in the assessment of a $50 penalty. (Section 6810, California Corporations Code, and Section 19141, Revenue and Taxation Code).

For further information, contact the Statement of Officers Unit at (916) 657-3537.


-----------------------------
INSTRUCTIONS FOR FILLING OUT THIS FORM
-----------------------------

Type or legibly print in black or blue ink.

· Make check payable to the Secretary of State.

· Send the executed document and filing fee to:

California Secretary of State
Statement of Officers
P.O. Box 944230
Sacramento, CA 94244-2300

· Please make a copy of the completed form and submit with the original if you wish an endorsed filed copy for your files.

Fill in the items as follows:

Item 1. Do not alter the preprinted corporate name. If the corporation name has been changed and is not correct, please attach a statement indicating the correct name and the date the name change amendment was filed with the Secretary of State. If the space is blank, enter the exact corporate name and number.

Item 2. Enter the complete street address, city, state and zip code, of the principal executive office in California, if any. DO NOT enter a P.O. Box or abbreviate the name of the city.

Item 3. Enter the mailing address of the corporation.

Item 4-6. Enter the name and complete business or residential address of the corporation's chief executive officer (i.e. president), secretary and chief financial officer (i.e. treasurer). DO NOT abbreviate the name of the city. The corporation must have these three officers (Section 5213, 7213, 9213, California Corporations Code). An officer may hold more than one office. You may add a title appropriate for your corporation but do not alter or obliterate preprinted titles.

Item 7. Enter the name of the agent for service of process in California. The person named as agent must be a resident of California or a corporation which has filed a certificate pursuant to Section 1505 of the California Corporations Code. If an individual is designated as agent, proceed to Item 8. If a corporation is designated, proceed to Item 9 (do not complete Item 8).

Item 8. If an individual is designated as the agent for service of process, enter a business or residential address in California. DO NOT enter "in care of" (c/o) or abbreviate the name of the city. DO NOT enter an address if a corporation is designated as the agent for service of process.

Section 1350, et seq., Civil Code mandates that a corporation formed on behalf of common interest development associations furnish specific additional information when filing a statement pursuant to Section 1502, California Corporations Code.

Item 9. Check the box if the corporation was not formed to manage a common interest development under the Davis-Stirling Common Interest Development Act and proceed to Item 11.

Item 10. Check the box if the corporation was formed to manage a common interest development under the Davis-Stirling Common Interest Development Act.

Item 10A. Enter the business or corporate office of the association, if any. If the office is not on the site of the common interest development, state the nine-digit zip code, front street, and nearest cross street for the physical location of the common interest development.

Item 10B. Enter the name and address of the association's managing agent, if any. (Section 1363.5, Civil Code)

Item 11. Type or print name of the signing officer or agent. Original signature and title of corporate officer or agent is required to complete the form. Enter date the form is signed.

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