Free RETURN TO - South Dakota

Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605)773-4845

ANNUAL REPORT
FOREIGN COOPERATIVE
Please Type or Print Clearly in Ink

FILE DATE

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RECEIPT NO ___________________

FILING FEE: $50 Make check payable to SECRETARY OF STATE
1. Corporate ID and Name:

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Telephone # ____________________ FAX # _______________________

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FILING DATE: Due during the month the Certificate of Authority was issued, and delinquent after the last day of the following month.

2. The jurisdiction under whose law it is formed ___________________________________________________________ 3. The address of the principal executive office in or out of the State of South Dakota. ______________________________________________________________________________________________
Street Address City State ZIP+4

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Mailing Address (Optional) City State ZIP+4

4. The name of the South Dakota Registered Agent _______________________________________________________ ______________________________________________________________________________________________
Street Address (Required to be a South Dakota Address) City State ZIP+4

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Mailing Address (Optional ­ Required to be a South Dakota Address) City State ZIP+4

5. The names and business addresses of its principal officers and directors. Please place a check mark next to the name if the principal officer serves as a director. _____________________________________________________________________________________________
President Street Address City State ZIP+4

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Vice President Street Address City State ZIP+4

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Secretary Street Address City State ZIP+4

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Treasurer Street Address City State ZIP+4

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Director Street Address City State ZIP+4

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Director Street Address City State ZIP+4

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General Manager Street Address City State ZIP+4

Dated ____________________________

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(Signature of an authorized officer)

______________________________________________
(Printed Name)

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(Title) Annualreportforeigncoop July 2009