Kansas Professional Corporation Annual Report Form

The following annual report has to be completed and submitted along with a $55 filing fee by any corporation that is registered in the State of Kansas.

Extracted Text for Proper Search

The following form must be complete and 
accompanied by the correct filing fee or the 
document will not be accepted for filing. 	k a n s a s  s e c r e ta ry  o f  s tat e
Kansas Professional Corporation
Annual Report
Instructions 	PA 
50 	
Kansas Of�ce of the Secretary of State: 
Memorial Hall, 1st Floor  (785) 296-4564
120 S.W. 10th Avenue  [email protected]
Topeka, KS 66612-1594  www.sos.ks.gov  Save time and money by filing your annual
report online at www.sos.ks.gov. There, 
you can also stay up-to-date on your
organization’s status, annual report due date,
and contact addresses. 
o	
Please proceed to form.

k a n s a s  s e c r e ta ry  o f  s tat e
Kansas Professional Corporation
Annual Report 	PA 
50 	
Kansas Of�ce of the Secretary of State: 
Memorial Hall, 1st Floor  (785) 296-4564
120 S.W. 10th Avenue  [email protected]
Topeka, KS 66612-1594  www.sos.ks.gov 	
THIS SPACE FOR OFFICE uSE ONly. 	
1. 	Business entity ID number 	
This is not the Federal Employer ID Number (FEIN). 	
2. 	Name of corporation 	
Must match name on record 
with Kansas Secretary of State. 	
3. 	Mailing address 	
Address will be used to 
send of�cial mail from the 
Secretary of State’s Of�ce. 
Do not leave blank. 	
4. 	Tax closing date 	
Please continue to next page.

8.  Name and address 

of each member of 
board of directors of 
corporation 	
If additional space is needed,
please provide attachment. 
Do not leave blank. 	
9. 	Name and address of 
each shareholder 	
If additional space is needed,
please provide attachment. 
Do not leave blank. 	
Name 1  Address 
City  State Zip  Country 
Name 2  Address 
City  State Zip  Country 
Name 1  Address 
City  State Zip  Country 
Name 2  Address 
City  State Zip  Country 	
10a. Is each of�cer, director, and shareholder listed above a quali�ed person as de�ned by law (K.S.A. 17-2707)? 	
Only a quali�ed person may be a shareholder of a professional corporation (K.S.A. 17-2712).  Exception:  A certi�ed public accountant (K.S.A. 1-308).
No person may be a director or of�cer, other than the secretary, of a professional corporation unless that person is a shareholder (K.S.A. 17-2713). 	
o	 	yes (Skip to 10c.)	 o	 No (Proceed to 10b.) 	
10b. List those persons who are not quali�ed as de�ned by law. 
10c. 	
If any shares are owned by a nonquali�ed person, give the dates on which any shares were owned by a nonquali�ed person: 	
11.  Indicate the types of professionals practicing through the corporation. 
o	Architect 	o	Veterinarian 	o	licensed Physical Therapist 	o	Certi�ed Public Accountant 	
o	Attorney-at-law 	o	Podiatrist 	o	landscape Architect 	o	licensed Physician Assistant 	
o	Chiropractor 	o	Pharmacist 	o	Registered Professional Nurse 	o	licensed Occupational Therapist 	
o	Dentist 	o	land Surveyor 	o	Clinical Professional Counselor 	o	licensed Audiologist 	
o	Engineer 	o	licensed Psychologist 	o	Geologist 	o	licensed Speech Pathologist 	
o	Optometrist 	o	Specialist in Clinical Social Work 	o	Clinical Psychotherapist 	o	licensed Naturopathic Doctor 	
o	Osteopathic Physician or 	o	Physician, Surgeon, or Doctor of 	o	Real Estate Broker or 	o	Clinical Marriage and Family
Surgeon  Medicine Salesperson Therapist 	
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. 
Signature of Authorized Officer 
X 	
Month  Day  Year 
Name of Signer (printed or typed)  Title/Position Phone Number 	
K.S.A. 17-2718			Please review to ensure completion.	2 / 2 	Rev. 9/12/11 jdr