Annual Benefit Report

Office of the Minnesota Secretary of State Minnesota Public Benefit Corporation / Annual Benefit Report Minnesota Statutes, Chapter 304A Read the instructions before completing this form Must be filed by March 31 Filing Fee: $55 for expedited service in-person, $35 if submitted by mail The Annual Benefit Report covers the 12 month period ending on December 31 of the previous year. Notice: Failure to file this form by March 31 of this year will result in the revocation of the corporation's public benefit status without further notice from the Secretary of State, pursuant to Minnesota Statutes, Section 304A.301 1. Corporate Name: (Required) 2. The public benefit corporation's board of directors has reviewed and approved this report. 3. In the field below, enter the information required by section 304A.301 subd. 2 or 3 for the period covered by this report, (see instructions for further information): Note: Use additional sheets if needed. (Required) 4. I, the undersigned, certify that I am the chief executive officer of this public benefit corporation. I further certify that I have signed this document no more than 30 days before the document is delivered to the secretary of state for filing, and that this document is current when signed. I further certify that I have completed all required fields, and that the information in this document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document under oath. Signature of Public Benefit Corporation's Chief Executive Officer Date (Must be dated within 30 days before the report is delivered to the Secretary of State for Filing) Email Address for Official Notices Enter an email address to which the Secretary of State can forward official notices required by law and other notices: Check here to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law. List a name and daytime phone number of a person who can be contacted about this form: Contact Name Phone Number Entities that own, lease, or have any financial interest in agricultural land or land capable of being farmed must register with the MN Dept. of Agriculture's Corporate Farm Program. Does this entity own, lease, or have any financial interest in agricultural land or land capable of being farmed? Yes No American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS This form is intended merely as a guide for filing and is not intended to cover all situations. Retain the original signed copy of this document for your records and submit a legible photocopy for filing with the Office of the Secretary of State. Before April 1, a public benefit corporation must file an annual benefit report covering the 12 month period ending on December 31 of the previous year. If a public benefit corporation fails to file, before April 1 of any calendar year, the corporation's status as a public benefit corporation will be revoked by the Office of the Minnesota Secretary of State. 1. Corporation Name: (Required) List the business name on file with the Office of the Minnesota Secretary of State. 2. Statement that board of directors has reviewed and approved this report. 3. Enter your information for the public benefit corporation's specific or general benefit corporation in this section. Please provide an attachment if there is not enough room to complete this section. For a specific benefit corporation, the annual benefit report must contain: (1) with regard to the period covered by the report, a narrative description of: (i) the ways in which the corporation pursued and created the specific public benefit stated in its articles; (ii) the extent to which that specific public benefit purpose was pursued and created; and (iii) any circumstances that hindered efforts to pursue or create the specific public benefit; and (2) a certification that its board of directors has reviewed and approved the report. For a general benefit corporation, the annual benefit report must: (1) certify that its board of directors has: (i) chosen the third-party standard designated pursuant to clause (2), item (i); (ii) determined that the organization that promulgated the third-party standard is independent; and (iii) approved the report; (2) with regard to the period covered by the report: (i) identify a third-party standard determined by the board; and (ii) with reference to that third-party standard, describe: (A) how the corporation has pursued general public benefit; (B) the extent to which and the ways in which the corporation has created general public benefit; and (C) any circumstances that hindered efforts to pursue or create general public benefit; (3) if the report is the first delivered for filing by the general benefit corporation, explain how and why the board chose the third-party standard identified under clause (2), item (i); (4) if the third-party standard identified under clause (2), item (i), is the same third-party standard identified in the immediately prior report: (i) state whether the third-party standard is being applied in a manner consistent with the third-party standard's application in the prior reports; and (ii) if the third-party standard is not being so applied in a consistent manner, explain why; (5) if the third-party standard identified under clause (2), item (i), is not the same as the third-party standard identified in the immediately prior report, explain how and why the board chose a different third-party standard; and (6) if the general benefit corporation has also stated a specific public benefit purpose in its articles, the information required in subdivision 2, clause (1). 4. A signature is required by the Public Benefit Corporation's chief executive officer. Email Address for Official Notices. This email address may be used to send annual renewal reminders and other important notices that may require action or response. Check the box if you wish to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law. List a name and daytime telephone number of a person who can be contacted about this form. Filing Fee payable to the Minnesota Secretary of State: There is a filing fee for filing the annual benefit report of $55 for expedited service in-person and $35 if submitted by mail. A corporation that has had their public benef