Attachment 22 - Statement of Information filed with the CA Secretary of State�• State of California
Secretary of State
STATEMENT OF INFORMATION
(Limited Liability Company)
Filing Fee $20.00. If this is an amendment, see instructions.
tnRTANT_ RFAn lKWrorfrTtnue
1. LIMITED LIABILITY COMPANY NAME
Los Gatos Senior Homes LLC
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FILED
Secretary of State
RM State of Califomia
AW O 5 2014
i
This Space For Filing Use Only
File Number and State or Place of Organization
2. SECRETARY OF STATE FILE NUMBER 201420510239 3. STATE OR PLACE OF ORGANIZATION in formed outside of Calfton)
4. If there have been any changes to the information Contained in the last Statement of Information filed with the Calffomia Secretary of
State, or no Statement of Information has been previously filed, this form must be completed in its entirety.
If there has been no change in any of the information contained In the last Statement of Information filed with the California Secretary of
State, check the box and proceed to Nom 15.
Complete Addresses for the Following (Do not abbmviate the new of the city. Items 5 and 7 cannot be P.O. Boxes.)
5. STREET ADDRESS OF PRINCIPAL OFFICE CITY STATE ZIP CODE
1400 Parkmoor Ave., Suite 190 San Jose CA 95126
6, MAILING ADDRESS OF LLD. IF DIFFERENT THAN rEM 6 CfTY STATF rP rnrx
7. STREET ADDRESS OF CALIFORNIA OFFICE
1400 Parkmoor Ave., Suite 190
STATE ZIP CODE
CA 95126
Name and Complete Address of the Chief Executive Officer, If Any
S. NAME ADDRESS CITY STATE ZIP CODE
Daniel Wu 1400 Parkmoor Ave., Suite 190 San Jose CA 95126
I
Name and Complete Address of Any Manager or Manager, or if None Have Been Appointed or Elected, Provide the Name and
Address of Each Member (Attach additional pages, if necessary.)
6. NAME ADDRESS CITY STATE ZIP CODE
Charities Housing Dev. Corp 1400 Parkmoor Ave., Suite 190 San Jose CA 95126
te. NAME ADDRESS CITY STATE ZIP CODE
11. NAME ADDRESS CITY STATE ZIP CODE
Agent for Service of Process If the agent Is an Individual, the agent must reside in California and Item 13 must be completed with a Caii(omia address, a
P.O. Box is not acceptable. If the agent Is a corporation, the agent must have on file with the California Secretary of State a certificate Pursuant to California
Corporations Code section 1505 and Item 13 must be left blank.
12. NAME OF AGENT FOR SERVICE OF PROCESS
Daniel Wu
13. STREETADDRESS OF AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL CITY STATE ZIP CODE
1400 Parkmoor Ave., Suite 190 San Jose CA 95126
Type of Business
14. DESCRIBE THE TYPE OF BUSINESS OF THE LIMITED LIABILITY COMPANY
To own and operate low income senior housino.
15. THE INFORMATION CONTAINED HEREIN, INCLUDING ANY ATTACHMENTS. IS TRUE AND CORRECT.
7/25/14 Terri Fukuda Controller
DATE TYPE OR PRIM NAME OF PERSON COMPLETING THE FORM TITLE SIGMA TUR
LLC42 (REV 01/014)
APPROVED BY SECRETARY OF STATE
ATTACFi1VFENT 2 2
1 hereby certify th t the toregoing
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la anonpf ea foil True an co" co of the
riginarecod In the custody of the
lifornia Secretary of State's office.
'AUG 112014 fi
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DEBRA BOWEN, Secretary of State