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TO CONDUCT ACTIVITIES STATEMENT OF FOREIGN QUALIFICATION (How to Start a Business)

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_____________________
Deputy Secretary of State
A True Copy When Attested By Signature
_____________________
Deputy Secretary of State
Filing Fee $250.00
FOREIGN
LIMITED LIABILITY COMPANY
STATE OF MAINE
STATEMENT OF FOREIGN QUALIFICATION
TO CONDUCT ACTIVITIES
______________________________________
(Name of Limited Liability Company in Jurisdiction of Organization)
Pursuant
to 31 MRSA §1622, the undersigned limited liability company executes and delivers the following Statem
ent of Foreign
Qualification:
FIRST: If the name of the limited liability company in the jurisdiction of organization does not contain one of the words or
abbreviations required by 31 MRSA § 1508.1 (“limited liability company” or “limited company” or the abbreviation
“L.L.C.,” “LLC,” “L.C.” o
r “LC” or, in the case of a low-profit limited liability company, “L3C” or “l3c”), the
proposed name to be used in this State in compliance with this requirement is: * (If not applicable, so indicate.)
_______________________________________________________________________________________________
SECOND: If the name of the limited liability company in the jurisdiction of organization is unavailable pursuant to 31 MRSA
§1508, the fictitio
us name under which it seeks authority to conduct activities in the State of Maine is: (If not
applicable, so indicate.)
______________________________________________________________________________________________
Form MLLC-5 accompanies this application. (See 31 MRSA § 1624.1)
THIRD:
Date of formation: ________________________ Jurisdiction where formed: _______________________________
Address of the principal office, wherever located:
_________________________________________________________________________________________
(physical location - street (not P.O. Box), city, state and zip code)
_________________________________________________________________________________________
(mailing address if different from above)
FOURTH: The foreign limited liability company is a foreign limited liability company as defined in 31 MRSA §1502.11.
FIFTH: The nat
ure of the business or purpose(s) to be conducted or promoted in the State of Maine is:
__________________________________________________________________________________________.
Form No. MLLC-12 (1 of 3)
SIXTH: The Registered Agent is a: (select either a Commercial or Noncommercial Registered Agent)
Commercial Registered Agent CRA Public Number: ____________________
__________________________________________________________________________________
(name of commercial registered agent)
Noncommercial Registered Agent
__________________________________________________________________________________
(name of noncommercial registered agent)
__________________________________________________________________________________
(physical location, not P.O. Box – street, city, state and zip code)
__________________________________________________________________________________
(mailing address if different from above)
SEVENTH: Pursuant to 5 MRSA §105.2, the registered agent listed above has consented to serve as the registered agent for this
lim
ited liability company.
EIGHTH: The name and business, residence and mailing address of each manager (if any):
NAME ADDRESS
____________________________________ ___________________________________________________
____________________________________ ___________________________________________________
____________________________________ ___________________________________________________
Names and addresses of additional managers are attached as Exhibit ____, and made a part hereof.
NINTH: The date on which the foreign limited liability company commenced or expects to commence conducting activities in
the State of Maine is _______________________________.
TENTH: Check only if applicable
This is a professional limited liability company qualified pursuant to 13 MRSA Chapter 22-A to provide
the following professional services (see 13 MRSA, chapter 22-A for information on what constitutes
professi
onal services):
____________________________________________________________________________________________
(type of professional services)
Form No. MLLC-12 (2 of 3)
ELEVENTH: (Check if applicable)
The foreign limited liability company is governed by an agreement that establishes or provides for the
establishment of designated series having separate rights, powers or duties with respect to specified property
or obligations of the foreign limited liability company or profits and losses associated with specified property
or obligations. Additional information required pursuant to MRSA 31 §1622.2.J are attached hereto as
Exhi
bit _________, and made a part hereof.
TWELFTH: This statement of qualification is accompanied by a certificate of existence or such other document that the Secretary of
State determines to be suitable for purposes of proving the valid existence of the foreign limited liability company
under the law of the State or other jurisdiction listed in item Third. The certificate or other document must not have
been issued more than 90 days before the delivery of this statement to the office of the Secretary of State.
Dated ______________________________ ___________________________________________________
(Authorized Signature**)
___________________________________________________
(Type or print name and capacity)
*Th
e limited liability company name as used in the State of Maine must contain one of the following: “limited liability company” or
“limited company” or the abbreviation “L.L.C.,” “LLC,” “L.C.” or “LC” or, in the case of a low-profit limited liability company, “L3C”
or “l3c” – see 31 MRSA 1508). If the limited liability company's name in its jurisdiction of organization com
plies with 31 MRSA § 1508
with the addition of these words, then no fictitious name filing is required pursuant to 31 MRSA §§ 1622.2.A and 1624.1.
**Statement MUST be signed by at least one authorized person (31 MRSA §1676.1B).
The execution of this statem
ent constitutes an oath or affirmation under the penalties of false swearing under 17-A MRSA §453.
Pl
ease remit your payment made payable to the Maine Secretary of State.
Submit completed form to: Secretary of State
Division of Corporations, UCC and Commissions
101 State House Station
Augusta, ME 04333-0101
Telephone Inquiries: (207) 624-7752 Email Inquiries: CEC.Corporations@Maine.gov
Form
No. MLLC-12 (3 of 3) 7/1/2011
Filer Contact Cover Letter
To: Department of the Secretary of State Tel. (207) 624-7752
Division of Corporations, UCC and Commissions
101 State House Station
Augusta, ME 04333-0101
Name of Entity (s):
_______________________________________________________________________
_______________________________________________________________________
List type of filing(s) enclosed (i.e. Articles of Incorporation, Articles of Merger, Articles of Amendment, Certificate
of Correction, etc.) Attach additional pages as needed.
________________________________________________________________________
________________________________________________________________________
Special handling request(s): (check all that apply)
Hold for pick up
Expedited filing - 24 hour service ($50 additional filing fee per entity, per service)
Expedited filing - Immediate service ($100 additional filing fee per entity, per service)
Total filing fee(s) enclosed: $ ________________
Contact Information – questions regarding the above filing(s), please call or email:
(failure to provide a
contact name and telephone number or email address will result in the return of the erroneous filing (s) by the Secretary of State’s office)
___________________________________ ___________________________________
(Name of contact person) (Daytime telephone number)
____________________________________________________
(Email address)
The enclosed filing(s) and fee(s) are submitted for filing. Please return the attested copy to the following
address:
______________________________________________________________________________
(Name of attested recipient)
_____________________________________________________________________________________________
(Firm or Company)
_____________________________________________________________________________________________
(Mailing Address)
_____________________________________________________________________________________________
(City, State & Zip)
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Completed 29 July 2020

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