HomeMy WebLinkAboutMom USA, LLC SOI.01112021SE P.I .0 F 'T F
sy Secretary of State
Statement of Information
Limited Liability Company) O4C iF0 PAP
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
LLC-12 21-Al 8369
FILED
In the office of the Secretary of State
of the State of California
JAN 11, 2021
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.)
MOM USA LLC
2. 12-Digit Secretary of State File Number 3. State, Foreign Country or Place of Organization (only if formed outside of California)
202029010202 CALIFORNIA
4. Business Addresses
a. Street Address of Principal Office - Do not list a P.O. Box City (no abbreviations) State Zip Code
630 Quintana Road, Suite #113 Morro Bay CA 93442
b. Mailing Address of LLC, if different than item 4a City (no abbreviations) State Zip Code
630 Quintana Road, Suite #113 Morro Bay CA 93442
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
630 Quintana Road, Suite #113 Morro Bay CA 93442
If no managers have been appointed or elected, provide the name and address of each member. At least one name and address
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
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 L1-C-12A (see instructions).
a. First Name, if an individual - Do not complete Item 5b Middle Name Last Name Suffix
Megan Souza
b. Entity Name - Do not complete Item 5a
c. Address City (no abbreviations) State Zip Code
630 Quintana Road, Suite #113 Morro Bay CA 93442
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
Eric Powers
b. Street Address (if agent is not a corporation) - Do not enter a P.O. Box City (no abbreviations) State Zip Code
630 Quintana Road, Suite #113 Morro Bay CA 93442
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 61b
7. Type of Business
a. Describe the type of business or services of the Limited Liability Company
Retail
8. Chief Executive Officer. if elected or appointed
a. First Name Middle Name Last Name Suffix
Megan Souza
b. Address City (no abbreviations) State Zip Code
630 Quintana Road, Suite #113 Morro Bay CA 93442
9. The Information contained herein, including any attachments, is true and correct.
01/11/2021 Mark B Cardona General Counsel
Date Type or Print Name of Person Completing the Form Title Signature
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: F 1
Company:
Address:
City/State/Zip: L J
LLC-12 (REV 01/2017) Page 1 of 2 2017 California Secretary of State
www.sos.ca.gov/business/be
4 SEpE ^oi'TyF
Attachment to
o
Statement of Information
Limited Liability Company)
9(FORR P
A. Limited Liability Company Name
MOM USA LLC
B. 12-Digit Secretary of State File Number
202029010202
LLC-12A
Attachment
21-Al 8369
This Space For Office Use Only
C. State or Place of Organization (only if formed outside of California)
CALIFORNIA
D. List of Additional Manager(s) or Member(s) - If the manager/member is an individual, enter the individual's name and address. If the
manager/member is an entity, enter the entity's name and address. Note: The LLC cannot serve as its own manager or member.
First Name
Eric
Middle Name Last Name
Powers
Suffix
Entity Name
Address
630 Quintana Road, Suite #113
City (no abbreviations)
Morro Bay
State
CA
Zip Code
93442
First Name Middle Name Last Name Suffix
Entity Name
Address City (no abbreviations) State Zip Code
First Name Middle Name Last Name Suffix7
Entity Name
Address City (no abbreviations) State Zip Code
First Name Middle Name Last Name Suffix7
Entity Name
Address City (no abbreviations) State Zip Code
First Name Middle Name Last Name Suffix7
Entity Name
Address City (no abbreviations) State Zip Code
First Name Middle Name Last Name Suffix
Entity Name
Address City (no abbreviations) State Zip Code
First Name Middle Name Last Name Suffix 7
Entity Name
Address City (no abbreviations) State Zip Code
LLC-12A - Attachment (EST 07/2016) Page 2 of 2 2016 California Secretary of State
www.sos.ca.gov/business/be