Fillable Submission Cover Sheet (California)

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Submission Cover Sheet (California)

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Secretary of State
Business Programs Division
Business Entities
1500 11th Street, Sacramento, CA 95814
P.O. Box 944260, Sacramento, CA 94244-2600
Submission Cover Sheet
For faster service, file online at bizfileOnline.sos.ca.gov.
Instructions:
• Complete and include this form with your paper submission. This information only will be
used to communicate in writing about the submission, if needed. This form will be
treated as correspondence and will not be made part of the filed document.
• Make all checks or money orders payable to the Secretary of State.
• In person submissions (excluding Statements of Information): $15 handling fee; do not include
a $15 handling fee when submitting documents by mail.
• Standard processing time for submissions to this office is approximately 5 business days from
receipt. All submissions are reviewed in the date order of receipt with online submissions
given priority. For updated processing time information, visit
www.sos.ca.gov/business/be/processing-dates.
Optional Copy and Certification Fees:
• If applicable, include optional certification fees with your submission.
• For applicable certification fee information, refer to the instructions of the specific form you are
submitting.
Contact Person: (Please type or print legibly)
First Name: Last Name:
Phone (optional):
Entity Information: (Please type or print legibly)
Name:
Entity Number (if applicable):
Address:
Comments
Submission Cover Sheet (REV 03/2022)
Clear Form
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Secretary of State
Statement of Information
(Limited Liability Company)
LLC-12
This form is due within 90 days of initial
registration and every two years thereafter.
Filing Fee - $20.00
Certification Fee (Optional) - $5.00
This Space For Office Use Only
1. Limited Liability Company Name (Enter the exact name of the LLC. If you registered in California using an
alternate name.)
2. 12-Digit Secretary of State Entity Number 3. State, Foreign Country or Place of Organization
(only if formed outside of California)
4. Business Addresses
a. Street Address of Principal Office - Do not list a P.O. Box
City (no abbreviations) State Zip Code
b. Mailing Address of LLC, if different than item 4a
City (no abbreviations) State Zip Code
c. Street Address of California Office, if Item 4a is not in California
Do not list a P.O. Box
City (no abbreviations) State
CA
Zip Code
5. Manager(s) or Member(s)
If no managers have been appointed or elected, provide the name and address of
each member. At least one name and address must be listed. If the
manager/member is an individual, complete Items 5a and 5c (leave Item 5b blank).
If the manager/member is an additional managers/members, enter the names(s)
and address(es) on Form LLC-12A
.
a. First Name, if an individual - Do not complete Item 5b Middle Name Last Name Suffix
b. Entity Name - Do not complete Item 5a
c. Address City (no abbreviations) State Zip Code
LLC-12 (REV 03/2022)
2022 California Secretary of State
bizfileOnline.sos.ca.gov
Page 1 of 2
6. Service of Process (Must provide either Individual OR Corporation.)
INDIVIDUAL – Complete Items 6a and 6b only. Must include agent’s full name and California street address.
a. California Agent's First Name (if agent is not a corporation) Middle Name Last Name Suffix
b. Street Address (if agent is not a corporation) - Do not enter a
P.O. Box
City (no abbreviations) State
CA
Zip Code
CORPORATION – Complete Item 6c only. Only include the name of the registered agent Corporation.
c. California Registered Corporate Agent’s Name (if agent is a corporation) – Do not complete Item 6a or 6b
7. Type of Business
Describe the type of business or services of the Limited Liability Company
8. Chief Executive Officer, if elected or appointed
a. First Name Middle Name Last Name Suffix
b. Address City (no abbreviations) State Zip Code
9. Labor Judgment
Does any Manager or Member have an outstanding final judgment issued by the
Division of Labor Standards Enforcement or a court of law, for which no appeal
therefrom is pending, for the violation of any wage order or provision of the Labor Code?
Yes No
LLC-12 (REV 03/2022)
2022 California Secretary of State
bizfileOnline.sos.ca.gov
10.0. Email Notifications
Provide an email address to opt-in to receive entity related notifications, including Statement of Information
reminders, by email rather than USPS mail. Note: If no email address is provided, you will continue to receive
notices and reminders by USPS mail.
Yes, I opt-in to receive entity notifications via email. Email Address: _____________________________________________
To change your option after filing, you must submit a new complete Statement of Information.
P
age 2 of 2
By signing, I affirm under penalty of perjury that the information herein is true and correct and that I am
authorized by California law to sign.
___
__________________
Date
____________________________________________________________
Type or Print Name
________________________ __________________________________
Title
Signature
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Submission Cover Sheet (California)

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Completed 21 June 2022

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