Annual Benefit Report Benefit Corporation {F0018}

STATE OF SOUTH CAROLINA SECRETARY OF STATE ANNUAL BENEFIT REPORT BENEFIT CORPORATION TYPE OR PRINT CLEARLY IN BLACK INK. FILING FEE $10 Pursuant to Section 33-38-500 of the 1976 South Carolina Code of Laws, as amended, the undersigned corporation hereby submits its most recent annual benefit report to the Secretary of State: 1. 2. The name of the benefit corporation is The attached annual benefit report is for the fiscal year beginning _________, 20___, and ending _________, 20___. Date Name of Corporation Signature of Officer Type or Print Name Position of Officer Telephone Number FILING INSTRUCTIONS 1. THIS FORM MUST BE ACCOMPANIED BY THE MOST RECENT ANNUAL BENEFIT REPORT DELIVERED TO SHAREHOLDERS AS REQUIRED UNDER S.C. CODE OF LAWS §33-38-500. Two copies of this form, including any attachments, must be submitted for filing. Include a self-addressed stamped envelope to have a filed copy returned to you by mail. If the space in this form is insufficient, please attach additional sheets containing a reference to the appropriate paragraph in this form. Enclose the filing fee of $10.00 made payable to the Secretary of State. 2. 3. 4. Return to: Secretary of State 1205 Pendleton Street, Suite 525 Columbia, SC 29201 American LegalNet, Inc. www.FormsWorkFlow.com