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Mailing address <br />(leave blank if same as street address) <br />15160 Hwv 144 #18 <br />(Street number and name or Post Office Box information) <br />Fort Morgan <br />(City) <br />Co 80701 <br />(State) (ZIP /Postal Code) <br />(The following statement is adopted by marking the box) <br />0 The person appointed as registered agent has consented to being so appointed. <br />5. (If the following statement applies, adopt the statement by marking the box and include an attachment.) <br />❑ This document contains additional information as provided by law. <br />6. (Caution: Leave blank if the document does not have a delayed effective date. Stating a delayed effective date has <br />significant legal consequences. Read instructions before entering a date) <br />(If the following statement applies, adopt the statement by entering a date and, if applicable, time using the required format.) <br />The delayed effective date and, if applicable, time of this document is /are <br />(mm/dd/y),y hour: minute am /pm) <br />Notice: <br />Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or <br />acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the <br />individual's act and deed, or that the individual in good faith believes the document is the act and deed of the <br />person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity <br />with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic <br />statutes, and that the individual in good faith believes the facts stated in the document are true and the <br />document complies with the requirements of that Part, the constituent documents, and the organic statutes. <br />This perjury notice applies to each individual who causes this document to be delivered to the Secretary of <br />State, whether or not such individual is named in the document as one who has caused it to be delivered. <br />7. The true name and mailing address of the individual causing the document to be delivered for filing are <br />Kokes Mark <br />15160 H <br />(Last) t144 #18 (First) (Middle) (Suffix) <br />(Street member and name or Post Office Box information) <br />Fort Morgan <br />CO 80701 <br />(City) (State) (ZIP /Postal Code) <br />United States <br />(Province — i(applicable) (Country) <br />(If the following statement applies, adopt the statement by marking the box and include an attachment.) <br />❑ This document contains the true name and mailing address of one or more additional individuals <br />causing the document to be delivered for filing. <br />Disclaimer: <br />This form/cover sheet, and any related instructions, are not intended to provide legal, business or tax advice, <br />and are furnished without representation or warranty. While this form/cover sheet is believed to satisfy <br />minimum legal requirements as of its revision date, compliance with applicable law, as the same may be <br />amended from time to time, remains the responsibility of the user of this form/cover sheet. Questions should <br />be addressed to the user's legal, business or tax advisor(s). <br />REG —LLP Page 2 of 2 Rev. 12/01/2012 <br />