HomeMy WebLinkAboutMOM USA LLC 29593085-1LLC-12SecretaryofState
Statement of Information
Limited Liability Company)
IMPORTANT — Read instructions before completing this form.
Filing Fee – $20.00
Copy Fees – First page $1.00; each attachment page $0.50;
Certification Fee - $5.00 plus copy fees
This Space For Office Use Only
1. Limited Liability Company Name (Enter the exact name of the LLC. If you registered in California using an alternate name, see instructions.)
2. 12-Digit Secretary of State File Number 3. State, Foreign Country or Place of Organization (only if formed outside of California)
4. Business Addresses
a. Street Address of Principal Office - Do not list a P.O. Box City (no abbreviations) State Zip Code
b. Mailing Address of LLC, if different than item 4a City (no abbreviations) State Zip Code
CA
Date Type or Print Name of Person Completing the Form Title Signature
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
If no managers have been appointed or elected, provide the name and address of each member. At least one name and address
must be listed. If the manager/member is an individual, complete Items 5a and 5c (leave Item 5b blank). If the manager/member is
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
has additional managers/members, enter the name(s) and addresses on Form LLC-12A (see instructions).
5. Manager(s) or Member(s)
a. First Name, if an individual - Do not complete Item 5b Middle Name Last Name Suffix
b. Entity Name - Do not complete Item 5a
c. Address City (no abbreviations) State Zip Code
6. Service of Process (Must provide either Individual OR Corporation.)
INDIVIDUAL – Complete Items 6a and 6b only. Must include agent’s full name and California street address.
a. California Agent's First Name (if agent is not a corporation) Middle Name Last Name Suffix
b. Street Address (if agent is not a corporation) - Do not enter a P.O. Box City (no abbreviations) State
CA
Zip Code
CORPORATION – Complete Item 6c only. Only include the name of the registered agent Corporation.
c. California Registered Corporate Agent’s Name (if agent is a corporation) – Do not complete Item 6a or 6b
7. Type of Business
a. Describe the type of business or services of the Limited Liability Company
8. Chief Executive Officer, if elected or appointed
a. First Name Middle Name Last Name Suffix
b. Address City (no abbreviations) State Zip Code
9. The Information contained herein, including any attachments, is true and correct.
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
person or company and the mailing address. This information will become public when filed. SEE INSTRUCTIONS BEFORE COMPLETING.)
Name:
Company:
Address:
City/State/Zip:
LLC-12 (REV 01/2017) 2017 California Secretary of State
www.sos.ca.gov/business/be
21-G56612
FILED
In the office of the Secretary of State
of the State of California
DEC 18, 2021
MOM USA LLC
202029010202 CALIFORNIA
93401
CA 93401
93401CA719PismoStreetSanLuisObispo
719 Pismo Street San Luis Obispo
719 Pismo Street San Luis Obispo
Powers
San Luis Obispo
MOM Inc.
719 Pismo Street San Luis Obispo 93401
Eric
719 Pismo Street 93401
CA
Souza
San Luis Obispo
Retail
Megan
719 Pismo Street CA 93401
12/18/2021 Mark Cardona General Counsel
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