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Kansas Secretary of State Ron Thornburgh Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-4564 kssos@kssos.org www.kssos.org

KANSAS SECRETARY OF STATE

Kansas Professional Corporation Annual Report
Out-of-state professional corporations use Form AR All information must be completed and the required fee submitted or this document will not be accepted for filing. Please read all instructions before completing this document.

PA
50

1. 	Business Entity ID Number: __________________________________
(This is not the FEIN)

2. Corporation name: _________________________________________ _________________________________________________________

(Name must match the name on record with the Secretary of State)


3. Mailing address (this address will be used to send official mail from the Secretary of State’s Office): _________________________________________________________
Address


Do not write in this space


_________________________________________________________

City State Zip


4. 	Tax closing date: _____________________________
Month Day Year

5. Federal Employer ID Number (FEIN): ________________________

6. List the names, titles and addresses of all officers of the corporation (do not leave blank):
Name Title Address City State Zip ___________________________________________________________________________________________

__________________________________________________________________________________________ ___________________________________________________________________________________________ __________________________________________________________________________________________

7. List the names and addresses of the board of directors of the corporation (do not leave blank):
Name Address City State Zip ___________________________________________________________________________________________

__________________________________________________________________________________________ ___________________________________________________________________________________________ __________________________________________________________________________________________
If additional officers or directors exist, please provide an attachment.

Rev. 12/1/07 nr	

K.S.A. 17-2718 1/3

8. List the names and addresses of all shareholders (do not leave blank):
Name	 Address City State Zip ___________________________________________________________________________________________

__________________________________________________________________________________________ ___________________________________________________________________________________________ __________________________________________________________________________________________
9. Total amount of capital stock issued: __________________________________ 10. Only a qualified person may be a shareholder of a professional corporation (K.S.A. 17-2712). No person may be a director or officer, other than the secretary, of a professional corporation unless that person is a shareholder (K.S.A. 17-2713). (Exception: A certified public accountant professional corporation.) (a) Is each officer, director and shareholder listed above a qualified person as defined by law (K.S.A. 17-2707)? YES ____ NO ____ (b) If NO, list those persons who are not qualified as defined by law: _______________________________________________________________________________________________ (c) If any shares are owned by a nonqualified person, give the dates on which any shares were owned by a nonqualified person: _______________________________________________________________________________________________

11. 	Indicate the types of professionals who practice through the corporation: ___ Certified Public Accountant ___ Architect ___ Attorney-at-Law ___ Chiropractor ___ Dentist ___ Engineer ___ Optometrist ___ Osteopathic Physician or Surgeon ___ Physician, Surgeon or Doctor of Medicine	 ___ Veterinarian ___ Podiatrist ___ Pharmacist ___ Land Surveyor ___ Licensed Psychologist ___ Specialist in Clinical Social Work ___ Licensed Physical Therapist ___ Landscape Architect ___ Registered Professional Nurse ___ Real Estate Broker or Salesperson ___ Clinical Professional Counselor ___ Geologist ___ Clinical Psychotherapist ___ Clinical Marriage and Family Therapist ___ Licensed Physician Assistant ___ Licensed Occupational Therapist ___ Licensed Speech Pathologist ___ Licensed Audiologist

12. 	I declare under penalty of perjury pursuant to the laws of the state of Kansas that the foregoing is true and correct and that I have remitted the required fee. (Do not leave blank.)

Signature of authorized officer	

Date (month, day, year)

Name of signer (printed or typed)	

Title/position

Phone number

Rev. 12/1/07 nr	

K.S.A. 17-2718 2/3

Important Information Please read before completing your annual report
All information on your annual report must be complete and correct and the filing fee
 must accompany this report or it will not be accepted for filing.
 Out-of-state professional corporations must use Form AR. Form PA is only for Kansas
 professional corporations.


1.	 The filing fee for the annual report is $55. If you are filing this annual report as part of a reinstatement due to forfeiture, you may owe a different fee (fees are listed with the reinstatement form). For more information, please call (785) 296-4564. 2.	 Please enclose a check or money order payable to the Secretary of State. Annual reports received without the appropriate fee will not be accepted for filing. Please do not send cash. 3.	 Mailing address: This is the address where you would like to receive official mail from the Secretary of State’s Office. 4.	 DUE DATE—Annual reports are due on the 15th day of the fourth month following the tax closing month. Example: If the tax closing month is December, the due date is April 15 of the following year. The annual report may be filed as early as January 1. 5.	 FORFEITURE DATE—If the annual report is not filed and the appropriate fee is not paid within 90 days following the due date, the business will be forfeited in Kansas. If the forfeited business wishes to return to active and good standing status, a reinstatement process is required and penalties will be assessed. Example: If the tax closing month is December, the due date is April 15, and the forfeiture date is July 15. A business must file the annual report and pay the annual report fee on or before the forfeiture date to avoid forfeiture. 6.	 CORRECTED ANNUAL REPORT—If you wish to correct information that was erroneously provided on a previously filed annual report, you may file a Corrected Document form (form COR). Complete the form and attach a complete and correct new Annual Report (form PA) and submit with a $55 filing fee. 7.	 Stay up-to-date on your organization’s status, annual report due date and contact addresses by going to www.kssos.org (under Quick Links, select Search business entity information). Notice: There is a $25 service fee for all checks returned by your financial institution.

Rev. 12/1/07 nr	

K.S.A. 17-2718 3/3


				
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