Dental Support Organization Statement Of Correction {3805}

Form 3805--General Information (Statement of Correction) The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant code provisions. This form and the information provided are not substitutes for the advice and services of an attorney. Commentary A Statement of Correction by a Dental Support Organization (DSO) is addressed by Section 73.005 of the Texas Business & Commerce Code, chapter 73, and Section 98.4 of the secretary of state's administrative rules found in 1 Texas Administrative Code Chapter 98. Pursuant to sections 73.005, Bus. & Comm. Code and 1 TAC §98.4, any changes to the information given on the DSO registration statement must be filed with the secretary of state quarterly. This form may be used to update the information as necessary. A Statement of Corrrection is due according to the following schedule: Quarter First (Jan 1-Mar 31) Second (Apr 1-Jun 30) Third (July 1-Sept 30) First (Oct 1-Dec 31) Statement of Correction Due: Not later than the 45th day after March 31 Not later than the 45th day after June 30 Not later than the 45th day after Sept 30 Not later than the 45th day after Dec 31 Instructions for Form Preliminary Information: Select the box indicating for which quarter the report is being filed and indicate the year. DSO Information: The registration must set forth the DSO's legal name, registration number and the date of the last filed registration Statement of Correction: A statement indentifying and correcting any changes to the information in the DSO registration statement. Execution: The registration must be signed by a person authorized to act by or on behalf of the DSO. Payment and Delivery Instructions: The filing fee for a DSO Statement of Correction is $50. Fees may be paid by personal checks, money orders, LegalEase debit cards or American Express, Discover, MasterCard, and Visa credit cards. Checks or money orders must be payable through a U.S. bank or financial institution and made payable to the secretary of state. Fees paid by credit card are subject to a statutorily authorized convenience fee of 2.7 percent of the total fees. The completed form, along with the filing fee and necessary attachments may be mailed to Secretary of State, Registrations Unit, P.O. Box 13193, Austin, Texas 78711-3193 or delivered to the James Earl Rudder Office Building, 1019 Brazos, 1st Floor, Austin, Texas 78701. Form 3805 Instruction Page 1 ­ Do not submit with filing. American LegalNet, Inc. www.FormsWorkFlow.com Form 3805 Rev. 06/2016 This space reserved for office use only Submit to: SECRETARY OF STATE Registrations Unit P O Box 13193 Austin, TX 78711-3193 512-475-0775 Filing Fee: $50 Year: Quarter: DENTAL SUPPORT ORGANIZATION STATEMENT OF CORRECTION First: Jan-Mar Second: Apr-Jun Third: Jul-Sep Fourth: Oct-Dec Dental Support Organization Information Dental Support Organization (DSO) Name: Registration Number: Date of Last Filed Registration: Statement of Correction Use the space below to identify the changes being made to the registration statement. Attach a separate sheet if necessary. Changes to ownership information and business support services may attach the addendum forms (Form 3803 and Form 3804) but identify in the space below if these changes are meant to add or replace the current information. Execution Date: BY: Signature of authorized person Printed or typed name of authorized person Form 3805 1 American LegalNet, Inc. www.FormsWorkFlow.com