Laserfiche WebLink
V . . 18—D27837 <br /> 45f Pa,n�:rhF <br /> Secretary of StLLC-12 <br /> ate <br /> Statement of Information FILED <br /> 4� (Limited Liability Company) <br /> �9(�FOPP�p <br /> In the office of the Secretary of State <br /> IMPORTANT—Read instructions before completing this form. of the State of California <br /> Filing Fee–$20.00 <br /> SEP 28, 2018 <br /> Copy Fees–First page$1.00; each attachment page$0.50; <br /> Certification Fee-$5.00 plus copy fees <br /> This Space For Office Use Only <br /> 1. Limited Liability Company Name(Enter the exact name of the LLC. If you registered in California using an alternate name,see instructions.) <br /> DYCORA TRANSITIONAL HEALTH -CALIFORNIA LLC <br /> 2. 12-Digit Secretary of State File Number 3. State,Foreign Country or Place of Organization(only if formed outside of California) <br /> 201627110091 CALIFORNIA <br /> 4. Business Addresses <br /> a.Street Address of Principal Office-Do not list a P.O.Box City(no abbreviations) State Zip Code <br /> 650 W Alluvial Ave. Fresno CA 93711 <br /> b.Mailing Address of LLC,if different than item 4a City(no abbreviations) State Zip Code <br /> 650 W Alluvial Ave. Fresno CA 93711 <br /> c.Street Address of California Office,if Item 4a is not in California-Do not list a P.O.Box City(no abbreviations) State Zip Code <br /> 650 W Alluvial Ave. Fresno CA 1 93711 <br /> If no managers have been appointed or elected,provide the name and address of each member.At least one name and address <br /> 5. Manager(s)or Member(s) must be listed. If the manager/member is an individual,complete Items 5a and 5c(leave Item 5b blank). If the manager/member is <br /> an entity,complete Items 5b and 5c(leave Item 5a blank). Note: The LLC cannot serve as its own manager or member. If the LLC <br /> has additional managers/members,enter the name(s)and addresses on Form LLC-12A(see instructions). <br /> a.First Name,if an individual-Do not complete Item 5b Middle Name Last Name Suffix <br /> Sean Foster <br /> b.Entity Name-Do not complete Item 5a <br /> c.Address City(no abbreviations) state I Zip Code <br /> 5935 S. Emerson, Suite 100 Indianapolis IN 146237 <br /> 6. Service of Process (Must provide either Individual OR Corporation.) <br /> INDIVIDUAL—Complete Items 6a and 6b only. Must include agent's full name and California street address. <br /> a.California Agent's First Name(if agent is not a corporation) Middle Name Last Name Suffix <br /> Williams <br /> b.Street Address(if agent is not a corporation)-Do not enter a P.O.Box City(no abbreviations) State Zip Code <br /> 650 W Alluvial Ave. Fresno CA 93711 <br /> CORPORATION—Complete Item 6c only. Only include the name of the registered agent Corporation. <br /> LCalifor nia Registered Corporate Agent's Name(if agent is a corporation)—Do not complete Item 6a or 6b <br /> 7. Type of Business <br /> a.Describe the type of business or services of the Limited Liability Company <br /> Provider Support <br /> 8. Chief Executive Officer,if elected or appointed <br /> a.First Name Middle Name Last Name Suffix <br /> b.Address City(no abbreviations) State Zip Code <br /> 9. The Information contained herein,including any attachments,is true and correct. <br /> 09/28/2018 Derek A Lane General Counsel <br /> Date Type or Print Name of Person Completing the Form Title Signature <br /> Return Address(Optional)(For communication from the Secretary of State related to this document,or if purchasing a copy of the filed document enter the name of a <br /> person or company and the mailing address.This information will become public when filed. SEE INSTRUCTIONS BEFORE COMPLETING.) <br /> Name: r <br /> Company: <br /> Address: <br /> City/State/Zip: L J <br /> LLC-12(REV 01/2017) Page 1 of 2 2017 California Secretary of State <br /> www.sos.ca.gov/business/be <br />