Cooperative Association Corporation Annual Report 2017

Mark Martin, Arkansas Secretary of State COOPERATIVE ASSOCIATION/ CORPORATION ANNUAL REPORT 2017 For the year ending 12/31/2016 Pursuant to A.C.A. § 4-30-114 (PLEASE TYPE OR PRINT CLEARLY IN BLACK INK) 1. Name of the Corporation: 2. Jurisdiction under which the corporation is incorporated: 3. Agent for Service of Process: Street Address: City: Mailing Address (if different than above): City: 4. Principal Office Street Address: City: State: Zip: State: Zip: State: Zip: Principal Office Mailing Address (if different than above): City: Email Address: 5. Names of Principal Officers: State: Zip: 6. The total number of authorized shares, itemized by class and series, if any, within each class: 7. The total number of issued and outstanding shares, itemized by class and series, if any, within each class: 8. Please include the names of stockholders and amount of stock owned by each and submit it with this annual report: I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days. Executed this ______________ day of _________________________, _____________ (Day) (Month) (Year) ________________________________________ Authorizing Officer (Type or Print in Black Ink) _______________________________________ Signature of Authorizing Officer (Sign in Black Ink) No Filing Fee Business and Commercial Services Division 1401 W. Capitol, Suite 250, Little Rock, Arkansas 72201-1094 Phone: 501-682-3409 or Toll Free: 888-233-0325 Email: arsos@sos.arkansas.gov · Website: www.sos.arkansas.gov American LegalNet, Inc. www.FormsWorkFlow.com Rev. 12/16