ANNUAL REPORT WORKSHEET
Company Name:
File Number:
Record ID Number (if known):
Instructions: Complete this worksheet in full and return to our office for processing.
Principal Place of Business: Street address where company is physically located
1.
_____________________________________________________________________________
Directors: Name and street address for ALL Directors (attach a separate sheet if necessary)
1.
_____________________________________________________________________________
2. _____________________________________________________________________________
3. _____________________________________________________________________________
4. _____________________________________________________________________________
5. _____________________________________________________________________________
Officer: Name and street address for only one Officer
1.
_____________________________________________________________________________
Title (check one): President Vice President Secretary Treasurer CEO CFO
Authorization:
I authorize Harvard Business Services, Inc. to complete my electronic filing. I understand that if I owe additional amounts or
did not fully complete this form, I will be contacted for payment and information before submitting my annual Franchise Tax
report. I also agree to Section 502b of the Delaware State Code which states, “If any officer or director of a corporation
required to make an annual Franchise Tax report to the Secretary of State shall knowingly make any false statement in the
report, such officer or director shall be guilty of perjury.” A service processing fee of $10 will be charged to all refund requests
that have not yet been approved by the state of Delaware. Once an annual report filing has been approved by the state of
Delaware, no fees can be returned.
Signature: _________________________________
Print Name: ________________________________
Title: Must be one of the persons listed above (check one):
President Vice President Secretary Treasurer CEO CFO Director
Return this completed worksheet via one of the following methods:
1. Fax to 302-645-1280
2. Email to payments@delawareinc.com
3. Mail to: Harvard Business Services, Inc., 16192 Coastal Highway, Lewes, DE 19958
