When completing items 5 through 7, set forth the name of the individual in the format specified. Do not use
prefixes (e.g., Mr., Mrs., Ms.). Use the suffix box only for titles of lineage (e.g., Jr., Sr., III) and not for
other suffixes or titles (e.g., M.D., Ph.D.).
5—Members: Each member must be an individual licensed to render the professional service of the
association. Provide the name and address of each member of the professional association. If the space
provided is insufficient, include the information as an attachment to this form for item 5.
6—Directors or Executive Committee Members: A professional association is governed and managed
either by a board of directors or an executive committee. Each director or committee member must be a
member of the association whose name appears in item 5. Provide the name and address of each member of
the board of directors or executive committee. If the space provided is insufficient, include the information
as an attachment to this form for item 6.
7—Officers: The officers of a professional association must include a president and secretary. Any one
person may serve in more than one office. Each officer must be a member of the association whose name
appears in item 5. The president of a professional association must also be a member of the board of
directors or executive committee whose name appears in item 6. Provide the name, address, and title of
each officer. If the space provided is insufficient, include the information as an attachment to this form for
item 7.
8—Statement of Licensure: The annual statement must include a statement that all members are licensed
to perform the type of service for which the association is formed, or, in the case of a multi-practice
professional association, that each member is licensed to perform professional services falling within the
scope of practice of the practitioner.
Execution: Pursuant to Section 302.012(b) of the BOC, the annual statement must be signed by an
authorized officer. Generally a governing person or managerial official of the entity signs a filing
instrument. The annual statement need not be notarized; however, before signing, please read the
statements on this form carefully. The designation or appointment of a person as registered agent by an
organizer or managerial official is an affirmation by the organizer or managerial official that the person
named in the instrument as registered agent has consented to serve in that capacity. (BOC § 5.2011)
A person commits an offense under Section 4.008 of the BOC if the person signs or directs the filing of a
filing instrument the person knows is materially false with the intent that the instrument be delivered to the
Secretary of State for filing. The offense is a Class A misdemeanor unless the person’s intent is to harm or
defraud another, in which case the offense is a state jail felony.
Filing Fees: The filing fee for an annual statement for a professional association is $35. The professional
association becomes delinquent for failure to file the annual statement by June 30
th
. If the professional
association has become delinquent for failure to file the annual statement by June 30
th
, the filing fee is the
original $35 for ninety (90) days following the delinquency notice.
Additional Documentation:
Name Change (optional): To change the name of the professional association at the same time of filing the
required annual statement, an amendment (Form 424 or 406, as appropriate) and filing fee of $150 and
Form 803 and filing fee (as stated in Filing Fees), must be submitted at the same time to the Reports Unit
for filing.
Reinstatement: If the annual statement is not filed within the ninety (90) day period following the second
notification, the existence of the domestic professional association will be terminated or the registration of
the foreign professional association will be revoked. The professional association may be relieved of the
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