Form SS3143 "Home Service Contract Provider Application" - Louisiana

What Is Form SS3143?

This is a legal form that was released by the Louisiana Secretary of State - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the Louisiana Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SS3143 by clicking the link below or browse more documents and templates provided by the Louisiana Secretary of State.

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Download Form SS3143 "Home Service Contract Provider Application" - Louisiana

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S
L
Commercial Division
TATE OF
OUISIANA
(225) 925-4704
S
S
ECRETARY OF
TATE
R. Kyle Ardoin
Fax Numbers
SECRETARY OF STATE
(225) 932-5314 Corporations
(225) 932-5317 Legal Services
(225) 932-5318 UCC
TRANSMITTAL INFORMATION
For All Business Filings
Please indicate below the level of service requested, payment and contact information
Routine
Expedite $30
Priority Expedite $50
24 hour processing
2-4 hour processing
Check or Money Order Enclosed
*Do not put credit card information on this form. You may save payment information in your geauxBIZ profile under master account.
Business Name (List exactly as it appears in documents)
Name of person filing document (evidence of filing will be mailed to this person, at address below)
Address
State
City
Zip Code
Daytime phone number
Fax number
Email address
NOTE: Louisiana Law requires all Louisiana notaries to print or type their name and notary or
bar roll number on the document.
Mailing Address: P. O. Box 94125, Baton Rouge, LA * 70804-9125
Office Location: 8585 Archives Ave., Baton Rouge, LA * 70809
Web Site Address: www.sos.la.gov
SS984 Rev. 06/18
S
L
Commercial Division
TATE OF
OUISIANA
(225) 925-4704
S
S
ECRETARY OF
TATE
R. Kyle Ardoin
Fax Numbers
SECRETARY OF STATE
(225) 932-5314 Corporations
(225) 932-5317 Legal Services
(225) 932-5318 UCC
TRANSMITTAL INFORMATION
For All Business Filings
Please indicate below the level of service requested, payment and contact information
Routine
Expedite $30
Priority Expedite $50
24 hour processing
2-4 hour processing
Check or Money Order Enclosed
*Do not put credit card information on this form. You may save payment information in your geauxBIZ profile under master account.
Business Name (List exactly as it appears in documents)
Name of person filing document (evidence of filing will be mailed to this person, at address below)
Address
State
City
Zip Code
Daytime phone number
Fax number
Email address
NOTE: Louisiana Law requires all Louisiana notaries to print or type their name and notary or
bar roll number on the document.
Mailing Address: P. O. Box 94125, Baton Rouge, LA * 70804-9125
Office Location: 8585 Archives Ave., Baton Rouge, LA * 70809
Web Site Address: www.sos.la.gov
SS984 Rev. 06/18
R. Kyle Ardoin
HOME SERVICE CONTRACT PROVIDER APPLICATION
Secretary of State
R.S. 51:3143
Enclose filing fee
Return to:
Commercial Division
$600 Initial Registration
P.O. Box 94125
$250 Renewal Registration
Baton Rouge, LA 70804-9125
Make remittance payable to Secretary of State
(225) 925-4704
Do Not Send Cash
www.sos.la.gov
STATE OF __________________________________
( ) Initial Registration
PARISH/COUNTY OF ________________________
( ) Renewal Registration
( ) Amended Registration
HOME SERVICE CONTRACT PROVIDER’S INFORMATION:
Applicant Name: ______________________________________________________________________________________________
As registered with Louisiana Secretary of State
Address: _____________________________________________________________________________________________________
Principal Office in state of organization
(Include City, State and Zip Code)
Mailing Address: _____________________________________________________________________________________________
(Include City, State and Zip Code)
Telephone Number: __________________________________ Alternate Telephone Number: _____________________________
(Include Area Code)
(Include Area Code)
CONTACT PERSON’S INFORMATION:
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
Telephone Number: __________________________________ Alternate Telephone Number: _____________________________
(Include Area Code)
(Include Area Code)
REGISTERED AGENT’S INFORMATION:
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
SS3143 Rev. 05/18
OFFICERS, DIRECTORS AND OWNERS
Provide the names and addresses of all officers, directors and owners of 10 percent or more of the business, as required
by R.S. 51:3143B. Provide an addendum if additional space is needed.
1.
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
Position: ___________________________________________________________
Ownership Percentage: ______________________________
2.
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
Position: ___________________________________________________________
Ownership Percentage: ______________________________
3.
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
Position: ___________________________________________________________
Ownership Percentage: ______________________________
4.
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
Position: ___________________________________________________________
Ownership Percentage: ______________________________
5.
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
Position: ___________________________________________________________
Ownership Percentage: ______________________________
6.
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
Position: ___________________________________________________________
Ownership Percentage: ______________________________
7.
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(Include City, State and Zip Code)
Position: ___________________________________________________________
Ownership Percentage: ______________________________
SS3143 Rev. 05/18
Signature of Applicant or Authorized Representative: ____________________________________________________________________
Printed Name of Applicant or Authorized Representative: ________________________________________________________________
On this _______ day of __________________________________ 20____, before me, personally appeared _________________________________,
to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he executed it as his free act and deed.
___________________________________________________________________________________
Notary Signature, Printed Name, and Notary/Bar Roll Number
AGENT’S ACKNOWLEDGMENT AND ACCEPTANCE OF APPOINTMENT
I hereby acknowledge and accept the appointment of registered agent for and on behalf of the above named entity.
Registered agent(s) signature(s):
____________________________________________________
____________________________________________________
Sworn to and subscribed before me, the undersigned Notary Public, on this date: __________________________________________
___________________________________________________________________
Notary Signature, Printed Name, and Notary/Bar Roll Number
SS3143 Rev. 05/18
INSTRUCTIONS
1. The initial registration form must be completely filled out and submitted to the Secretary of State’s
Office along with a copy of its organizational documents (Articles of Incorporation, Articles of
Organization, Articles of Association, Partnership Agreement), a surety bond issued by a company
licensed to do business in Louisiana in the amount of $50,000 and the filing fee of $600.
2. The provider must be registered with the Louisiana Secretary of State’s Office and must be in good
standing.
3. The registration is effective for two years. The renewal application must be submitted to the Secretary of
State’s Office, along with a surety bond issued by a company licensed to do business in Louisiana in the
amount of $50,000, 90 days prior to the expiration of the registration. The renewal registration fee is
$250.
4. Changes to the registration form can be made by filing an amended registration, accompanied by
supporting documentation (amendments to the Articles of Incorporation, Articles of Organization,
Articles of Association or Partnership Agreement), with the Secretary of State’s Office within 60 days of
the effective date of the change. If the amendment is not due to any changes to the organizational
documents, a statement to the fact can be submitted. There is no fee to amend the registration.
SS3143 Rev. 05/18
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