SWA000069_LLC ANNUAL REPORT_5/6/2020

NAME OF LIMITED LIABILITY COMPANY:
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION:
REPORT FOR THE CALENDAR YEAR:
SECTION A: REGISTERED AGENT'S INFORMATION
1.NAME OF REGISTERED AGENT:
2.SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3.REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4.REGISTERED AGENT OFFICE MAILING ADDRESS
SECTION B: PRINCIPAL OFFICE INFORMATION
1.DESCRIPTION OF NATURE OF BUSINESS:
2.PRINCIPAL OFFICE PHONE NUMBER:3.PRINCIPAL OFFICE EMAIL:
4.PRINCIPAL OFFICE STREET ADDRESS 5.PRINCIPAL OFFICE MAILING ADDRESS
6. Select one of the following if applicable. (Optional see instructions)
The company is a veteran-owned small business
The company is a service-disabled veteran-owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
DATE
Print or Type Name of Company Official Print or Type Title of Company Official
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525
Filing Office Use Only
Changes
10/2017
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North Carolina Department of the Secretary of State
Elaine F. Marshall, Secretary

BELOW IS THE CHECK LIST FOR LIMITED LIABILITY COMPANY ANNUAL REPORT. Please take a few minutes and read the
information provided. The Limited Liability Company Annual Report is due by April 15th of each year, with the filing fee of
$200.00.
Each Limited Liability Company filing an annual report with the North Carolina Department of Secretary of State must
provide the following information:
1. NAME OF LIMITED LIABILITY COMPANY
2. STATE OF FORMATION
3. ANNUAL REPORT CALENDAR FILING YEAR
4. THE REGISTERED AGENT'S NAME AND SIGNATURE IF CHANGED
5. THE REGISTERED AGENT'S STREET ADDRESS AND MAILING ADDRESS IF DIFFERENT.
6. THE PRINCIPAL OFFICE ADDRESS, COUNTY AND TELEPHONE NUMBER
7. THE NAMES, TITLES AND BUSINESS ADDRESSES OF THE COMPANY OFFICIALS
8. A BRIEF DESCRIPTION OF THE NATURE OF BUSINESS

SECTION A: REGISTERED AGENT’S INFORMATION
1. The name of the registered agent must be typed or printed.
2. If the registered agent has changed, the new registered agent MUST SIGN CONSENT to the appointment in the space provided. If the registered agent's
name has changed due to marriage, or by any other legal means, the limited liability company must indicate such change in the space provided and have the
agent sign consent to the appointment under their new name. If the new registered agent is a business entity, then the appropriate representative of that
entity must sign and print their name and title. The registered agent must reside in North Carolina.
3. If the street address of the registered office has changed, indicate the change. The address of the registered office must be a Street Address and NOT a
Post Office Box Address. The street address of the registered office must be a North Carolina address.
4. If the mailing address of the registered office has changed it should be indicated in this item. The registered office's mailing address may be a Post Office
Box. The registered office mailing address must be a NORTH CAROLINA ADDRESS.

SECTION B: PRINCIPAL OFFICE INFORMATION

1. Provide a brief description of the nature of the LLC's business.
2. Enter the principal office telephone number.
3. Enter the principal office E-mail address.
4. The principal office address should reveal the limited liability company's physical location. The principal office street address must be a street address
and NOT a Post Office Box Address.
5. The principal office mailing address may be a Post Office Box.
6. You may voluntarily report whether the company qualifies as a service-disabled veteran-owned or veteran-owned small business. The annual net receipts
cannot exceed one million dollars ($1,000,000) to report as either veteran-owned small business designation. Choose the designation of a service-disabled
veteran-owned small business if one or more service-disabled veterans owns more than 50% of the business. Choose the designation of veteran-owned small
business if one or more veteran owns more than 50% of the business. For further definitions see N.C.G.S. §55-1-40; §57D-1-03; or §59-32.

SECTION C: COMPANY OFFICIALS

Enter the name, title and business address of each company official. Use Section E or a plain 8 1/2 X 11 sheet of paper if more space is needed. A
person listed in this section must sign the annual report and is then authorized to sign on other documents filed with this office.

SECTION D: CERTIFICATION OF ANNUAL REPORT

Check the annual report carefully to ensure all information required for filing has been provided. Only a company official listed on this report or past
completed and filed report may sign. Complete the signature, date, title and typed or printed name in the space provided on the form to certify that the
information is accurate and current. If the company official is another business entity then the appropriate representative of that business entity must certify
the annual report.

SECTION E: ADDITIONAL COMPANY OFFICIALS
Enter the name, title, and business address of each additional company official. A person listed in this section is then authorized to sign on other
documents filed with this office.
Mail the annual report to: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525. For information or assistance,
please contact the Business Registration Division at [phone] or Toll Free 1-888-246-7636. Web address is http://www.sosnc.gov. (Revised 10/2017)
IF THE INFORMATION REQUIRED TO BE ENTERED IN SECTION A THROUGH SECTION C HAS NOT CHANGED SINCE THE MOST
RECENTLY FILED ANNUAL REPORT, COMPLETE HEADER SECTION AND SECTION D TO CERTIFY THE ANNUAL REPORT.