Amendment Or Correction To Biennial Report

Amendment or Correction to Biennial Report , Secretary of State P.O. Box 94608 Lincoln, NE 68509 (402)471-4079 1)Exact Name of Corporation (exact name as stated in articles of incorporation or certificate of authority filed with theNebraska Secretary of State): 2)Amendment or Correction applies to the following type of Biennial Report (check only one box): Foreign Corporation Domestic Corporation 3)Years of Biennial Report being corrected (found on Report form):-(note you must file a separate form for each reporting period being corrected) 4)Amendment or Correction is correcting or adding names of (check boxes as applicable): Officer and indicate title of office and/or Director (attach additional page if necessary) (Indicate whether change or addition is Officer (give title) or Director and provide both name and address of same) (Indicate whether change or addition is Officer (give title) or Director and provide both name and address of same) 5)Amendment or Correction is correcting Principal Office:Street Address City State Zip 6)Amendment or Correction is correcting name of state or jurisdiction under whose laws the corporation isformed: 7)Amendment or Correction is correcting Nature of Business conducted in Nebraska: 8)Amendment or Correction is changing Location of Property Owned or Used in Nebraska: 9)Amendment or Correction is changing the Actual Value of Real Estate and Personal Property in Nebraska (ifForeign Corporation only): from $ to $ . (Enclose additional occupation tax due for Corporation or if refund is due contact Secretary of State for refund form. Attach explanation of increase ordecrease in Actual Value of Real Estate or Personal Property.) OR Amendment or Correction is changing the Amount of Paid Up Capital Stock (if Domestic Corporation only): from $ to $ . (Enclose additional occupation tax due for Corporation or if refund is due, contact Secretary of State for refund form. Attach explanation of increase or decrease in Amount of Paid Up Capital Stock.) Signature FILING FEES: $30.00 (plus $5.00 for any additional pages). Make check payable to: Secretary of State. Revised Neb. Rev. Stat. 247 21-301, 21-304 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING AMENDMENT OR CORRECTION TO BIENNIAL REPORT FORM 1.Name--Please state the exact name of the Foreign Corporation or Domestic Corporation, as it appearsin the Articles of Incorporation or Certificate of Authority filed with the Nebraska Secretary of State. 2.Type of Biennial Report being amended or corrected: Select the check box which corresponds to thetype of Biennial Report this Amendment or Correction refers to either Foreign or Domestic Corporation. 3.Reporting period-The amending party is required to submit a separate Amendment or Correction formfor each prior biennial report being corrected or amended and pay applicable fee for each form to be filed(see below). 4.Officer or Director changes or additions: For a change or addition to an Officer, you must provideofficer222s name and the title of the office (example: President) and complete address. For Director changesor additions, provide the name of the director and complete address. 5.Address of Principal Office: Please provide the complete address if amending or correcting thePrincipal Office. 6.Correction to Name of State or Jurisdiction: Please provide the name of the state or jurisdiction underwhose laws it was originally filed. 7.Nature of Business: State the amended or corrected nature of business conducted in Nebraska. 8.Location of Property Owned or Used in Nebraska: State the amended or corrected location of propertyowned or used in Nebraska. 9.Actual Value of Real Estate and Personal Property in Nebraska (if Foreign Corporation) OR Amountof Paid Up Capital Stock (if Domestic Corporation): Select the applicable check box for the type ofcorporation. Provide the original dollar amount reported on the Biennial Report being amended orcorrected and the corrected dollar amount. (Enclose additional occupation tax due for reporting period orif refund is due, contact Secretary of State for refund form to submit with this Amendment or Correction.Attach explanation of increase or decrease in Actual Value of Real Estate or Personal Property (if ForeignCorporation) or Amount of Paid Up Capital Stock (if Domestic Corporation). 10.Signature of person completing the Amendment or Correction to Biennial Report Filing fee is $30.00 (plus $5.00 per page for any additional pages) Make check payable to: Secretary of State. American LegalNet, Inc. www.FormsWorkFlow.com