Organization And First Report (Stock Or Nonstock Corp)

SECRETARY OF THE STATE OF CONNECTICUT MAILING ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, P.O. BOX 150470, HARTFORD, CT 06115-0470 DELIVERY ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, 30 TRINITY STREET, HARTFORD, CT 06106 PHONE: 860-509-6003 WEBSITE: www.concord-sots.ct.gov ORGANIZATION AND FIRST REPORT STOCK OR NON-STOCK CORPORATIONS USE INK. COMPLETE ALL SECTIONS. PRINT OR TYPE. ATTACH 81/2 X 11 SHEETS IF NECESSARY. FILING PARTY (CONFIRMATION WILL BE SENT TO THIS ADDRESS): FILING FEE: $150 EXCEPTION: $50.00 FILING FEE FOR NONSTOCK (NONPROFIT) CORPORATIONS. MAKE CHECKS PAYABLE TO "SECRETARY OF THE STATE" NAME: ADDRESS: CITY: STATE: ZIP: 1. NAME OF CORPORATION: 2. DATE OF ORGANIZATION MEETING: 3. ADDRESS OF PRINCIPAL OFFICE: (P.O.BOX UNACCEPTABLE) ADDRESS: CITY: STATE: ZIP: 4. MAILING ADDRESS (IF OTHER THAN PRINCIPAL OFFICE ADDRESS): ADDRESS: CITY: STATE: ZIP: 5. OFFICERS: A. OFFICER'S NAME: RESIDENCE ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: TITLE: BUSINESS ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: CITY: STATE: ZIP: CITY: STATE: ZIP: PAGE 1 OF 2 FORM COS-1-1.0 Rev. 12/2011 B. OFFICER'S NAME: RESIDENCE ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: TITLE: BUSINESS ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: CITY: STATE: ZIP: CITY: STATE: ZIP: C. OFFICER'S NAME: RESIDENCE ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: TITLE: BUSINESS ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: CITY: STATE: ZIP: CITY: STATE: ZIP: 6. DIRECTORS: A. DIRECTOR'S NAME: RESIDENCE ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: BUSINESS ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: CITY: STATE: ZIP: CITY: STATE: ZIP: B. DIRECTOR'S NAME: RESIDENCE ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: BUSINESS ADDRESS: (P.O.BOX UNACCEPTABLE) ADDRESS: CITY: STATE: ZIP: CITY: STATE: ZIP: 7. ELECTRONIC MAIL (EMAIL) ADDRESS: 8. EXECUTION: DATED THIS NAME OF SIGNATORY (print/type) DAY OF CAPACITY/TITLE OF SIGNATORY , 20 SIGNATURE PAGE 2 OF 2 FORM COS-1-1.0 Rev. 12/2011 INSTRUCTIONS FOR COMPLETION OF THE ORGANIZATION REPORT CORPORATION Instructions correspond with numbered entries on the form 1. NAME OF CORPORATION: Please provide the complete name of the corporation as it currently appears on the records of the Secretary of the State. 2. DATE OF ORGANIZATION MEETING: Please provide the month, day and year on which the organization meeting took place. 3. ADDRESS OF PRINCIPAL OFFICE: Please provide a complete address of the corporation's principal office including a number, street, city, state and postal code.P.O. boxes are only acceptable as additional information. 4. MAILING ADDRESS: Please provide the address to which the Secretary of the State should mail the corporation's annual report form, if other than its principal office address. A P.O. Box is acceptable for this address. 5. OFFICERS: Please provide the name of all of the corporation's officers, their titles and their residence and business addresses. Complete street addresses including a street number, street name, city, state, postal code and country if other than the United States are required. Note: P.O. boxes are only acceptable as additional information. 6. DIRECTORS: Please provide the name of all of the corporation's directors and their residence and business addresses. Complete street addresses including a street number, street name, city, state, postal code and country if other than the United States are required. Note: P.O. boxes are only acceptable as additional information. 7. ELECTRONIC MAIL ADDRESS: Please enter the corporation's email address (if any). 8. EXECUTION: The document must be executed by an authorized official of the corporation. That person must print or type their name, state the capacity under which they sign and provide a signature. The execution constitutes a legal statement under the penalties of false statement that the information provided in the document is true. OFFICE OF THE SECRETARY OF THE STATE MAILING ADDRESS: COMMERCIAL RECORDING DIVISION CONNECTICUT SECRETARY OF THE STATE P.O. BOX 150470 HARTFORD, CT 06115-0470 DELIVERY ADDRESS: COMMERCIAL RECORDING DIVISION CONNECTICUT SECRETARY OF THE STATE 30 TRINITY STREET HARTFORD, CT 06106 PHONE: 860-509-6003 WEBSITE: www.concord-sots.ct.gov INSTRUCTIONS DO NOT SCAN THIS PAGE FORM COS-1-1.0 Rev. 12/2011