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                                                                                                             SECRETARY OF STATE 
                FOREIGN REGISTRATION STATEMENT                                                            BUSINESS SERVICES DIVISION 
                State Form 56369 (R5 / 6-19)                                                              302 West Washington Street, Room E018 
                                                                                                             Indianapolis, IN 46204 
                                                                                                           Telephone: (317) 232-6576 
                                                                                                               www.sos.in.gov  
INSTRUCTIONS:  1. Use 8½” x 11” white paper for attachments. 
    2. Please   or          TYPE     PRINT in INK.  
                      3. Please visit our office on the web at www.sos.IN.gov 
                      4. Make check or money order payable to the Secretary of State.  
                      5. Submit original completed paperwork and payment to: 302 West Washington Street, Room E-018, Indianapolis, IN 46204. 
 
REQUIREMENTS:  1.        Applicants must submit a certificate of existence issued by the proper authority within the last sixty (60) days. 
                      2. Professional corporations must complete the professional license information below. 
 
                INFORMATION CONTAINED ON THIS PAGE IS NOT PART OF THE PUBLIC RECORD. 
 
Name    of business 
      
E-mail  address of business (SOS use only) 
      
RETURN DOCUMENTS TO: 
 
 Name 
      
Street  address, line 1 
      
Street  address, line 2 
      
 City                                                                 State                                ZIP code 
                                                                                                                 
Telephone   number                                E-mail address (If different from above – SOS use only) 
(     )                                                 
 
                                                  FOR PROFESSIONAL CORPORATIONS ONLY 
Please complete the following section so the Indiana Secretary of State can verify licensing information. 
Information for only one shareholder is required. 
                   Name                                        Address                          Profession   Indiana License        Status 
                                             (number and street, city, state, and ZIP code)                     Number 

                                                                                                                               Shareholder 

                                                                                                                               Shareholder 

                                                                                                                               Shareholder 

                                                                                                                               Shareholder 

                                                                                                                               Shareholder 

              FOREIGN REGISTRATION STATEMENT 
              State Form 56369 (R5 / 6-19) 
              
                                                                                                                                                            FILING FEE: 
                                                                                                                                 For-Profit Entities: $125.00 
                                                                                                                                 Foreign Master LLCs: $250.00 
                                                                                                                                 Nonprofit Corporations: $75.00 
 
                                                             FOREIGN REGISTRATION STATEMENT 
The undersigned, desiring to register a foreign entity with the Secretary of State pursuant to the provisions of Indiana Code 23-0.5-5-3, executes the 
following Foreign Registration Statement. 
 
                                                                   ARTICLE I – NAME OF ENTITY 
Legal name of the entity (The name must comply with Indiana Code 23-0.5-3-1.) 
      
If the name does not comply with Indiana Code 23-0.5-3-1, the alternate name of the entity adopted under Indiana Code 23-0.5-5-6 
      
                                                             ARTICLE II – ENTITY INFORMATION 
Entity type (select one) 
  Corporation, including Benefit Corporation and Professional Corporation                       Nonprofit Corporation             Limited Liability Company 
  Master Limited Liability Company                                                              Limited Liability Partnership     Limited Partnership 
If the entity is a nonprofit corporation, indicate if the corporation will have members. 
                                                                                          Yes    No members 
If the corporation had been incorporated in Indiana, it would be a (select one): 
  Public Benefit Corporation                                  Mutual Benefit Corporation                                       Religious Corporation 
If the entity is a Limited Liability Company or Master Limited Liability Company, the Limited Liability Company will be managed by its manager or managers. 
                                                                    Yes                   No     The LLC will be a single-member LLC. (optional) 
If the entity is a Master Limited Liability Company, the Master LLC is authorized transact business in Indiana in accordance with Indiana Code 23-18.1 
and is organized under a law that allows for the designation of one (1) or more series. 
The jurisdiction of formation 
      
Date the entity was formed in its jurisdiction of formation (month, day, year) 
      
                                                                   ARTICLE III – STREET ADDRESS 
The street address of the foreign entity: 
Number and street                                                                                      City                      State ZIP code 
                                                                                                                                             
                                                ARTICLE IV – REGISTERED AGENT INFORMATION 
To determine if your Registered Agent is a Commercial Registered Agent (CRA), go to INBIZ.in.gov.  
Provide either commercial registered agent or noncommercial registered agent information below. 
                                          Name of registered agent (Do not provide address.) 
  Commercial registered agent                   
OR 
                                          Name of registered agent 
  Noncommercial registered agent                
Address (number and street) (A P.O. Box is not acceptable unless accompanied by a Rural Route number.) City                      State ZIP code 
                                                                                                                                 IN          
(OPTIONAL) E-mail address of the registered agent at which the registered agent will accept electronic service of process 
      
   By checking the box, the Signator(s) represent(s) that the Registered Agent named in this Foreign Registration Statement has consented to the  
   appointment of Registered Agent. 
 
In Witness Whereof, the undersigned duly authorized representative of the entity executes this Foreign Registration Statement and verifies,  
 
subject to penalties of perjury, that the statements contained herein are true, this ______ day of ________________________, 20______. 
Signature 

Printed name                                                                             Title 
                                                                                               
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