State Renewal & Contact Information Questionnaire

Please answer the following question(s) below so we can properly file your Annual Report with the Secretary of State. If this form is not returned the previous year’s information will stay as is with the State.

Confirm the name of the entity being renewed:*
What State is your entity located in?*
Is the Entity being registered, owned by a Veteran?*
- Yes
- No
The Follow Questions are Required by the state of New Jersey:
Is this a business that is qualified and will provide self-insurance?*
- Yes
- No
If not self-insured, list Workers’ Compensation Insurance:
Insurance Company:*
Policy Number:*
Date Coverage began MM/DD/YYYY :*
MM slash DD slash YYYY
The Follow Questions are Required by the state of North Carolina:
Are you a U.S. Veteran?*
- Yes
- No
If yes, are you disabled?*
- Yes
- No
The Follow Questions are Required by the state of Washington:
Does your Company own land, buildings, or other real property in Washington?*
- Yes
- No
Has there been a transfer of stock, other financial interest change, or an option agreement exercised during the last 12 months that resulted in a transfer of controlling interest?*
- Yes
- No
Has an option agreement been executed in the last 12 months allowing for the future purchase or acquisition of the entity, that, if exercised would result in a transfer of controlling interest?*
- Yes
- No
Please note*: If your Company owns land, buildings, or other real estates in Washington state, you must contact the Washington State Department of Revenue to report a transfer of Controlling Interest. Failure to report the transfer is subject to the penalty provisions of RCW 82.45.220.
The Follow Questions are Required by the state of Wyoming:
Appendix 1 Worksheet - Annual Report - Not a Public Record
List only Assets Located and Employed in Wyoming
A balance sheet is provided below (similar to Schedule L of IRS Form 1120, 1120S, or Form 1065 for partnerships) showing the items to be included in computing "total assets" (with the three exceptions):
1. Cash:*
2a. Trade Notes & Accounts Receivable:*
2b. Subtract Allowance for bad debts:*
3. Inventories:*
4. U.S. Government Obligations:*
5. Tax-Exempt Securities:*
6. Other Current Assets:*
7. Loans to Stockholders:*
8. Mortgage and Real Estate Loans (loans or investments owned not your debts):*
9. Other Investments:*
10. Buildings & Other Depreciable Tangible Assets, real and personal (Use  assessed valuation). DO NOT subtract accumulated depreciation from assessed valuation. For depreciable assets which are not assessed, use balance sheet depreciation subtracted:*
11. Depletable assets (soda, coal, mineral oil, precious metals, saline, or other valuable deposits); the value is equal to the assessed value of the gross product produced for the fiscal year most recently ended:*
12. Land (Use assessed valuation.):*
13a. Intangible Assets:*
13b. Subtract Accumulated Amortization:*
14. Other Assets:*
Total Asset Value for computing tax (add lines 1-14):*
What is the purpose of the business?*
Are you a current member of our Mail Forward Program?*
- Yes
- No
Principle Office, Mailing Address, LLC, and Corporation with the following address:
1883 W Royal Hunte Dr,
Ste 200-A
Cedar City, Utah, 84720
List the Principle Office Address of the entity you would like listed with the Secretary of State (Must be a physical street address):*
Street Address Address Line 2 City State ZIP Code
List the Mailing Address of the entity you would like listed with the Secretary of State (if) different than the Principle Address. (PO Boxes acceptable)*
Street Address Address Line 2 City State ZIP Code
Confirm the Registered Agent:*
First Last
Address of Registered Agent:*
Street Address Address Line 2 City State ZIP Code
Please select the type of entity being renewed:*
- Corp
- LLC
- LP/LLP
President Name:*
First Last
President's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secretary Name:*
First Last
Secretary's Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Treasurer's Name*
First Last
Treasurer's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How Many Director's*
Director 1 - Name*
First Last
Director 1 - Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Director 2 - Name*
First Last
Director 2 - Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Director 3 - Name*
First Last
Director 3 - Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Director 4 - Name*
First Last
Director 4 - Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Director 5 - Name*
First Last
Director 5 - Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If you have a Corporation list the President, Secretary, Treasurer & all Directors & Shareholders Names and Share Amounts: (this is needed for the Secretary of State)*
If you have an LLC list the Names of all Members and Membership Units owned. List the Names of each Manager(s).*
What is the current number of Members or Shareholders to date:*
Please update the Contact Information that you would like listed with our office for billing and communication with KKOS.
Name of Contact:*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Disclaimer:
- Early payment does not guarantee early renewal.
- Renewals with the Secretary of State are completed within the month of the payment due date.
- If the questionnaire is not completed and submitted to our office by the due date on the invoice, the previous year’s information will stay “as is” with the state.
- Changes that are not submitted by the due date on the invoice, may accrue additional fees.
- If you are also a client of Kohler & Eyre CPA’s, please be aware that we cannot collect information for you, as this violates client confidentiality laws.
- The questionnaire is not the proper avenue for seeking legal advice or asking questions.
If you have any questions please contact Jennifer Parker at [email protected] for assistance.
Phone
This field is for validation purposes and should be left unchanged.