00811990 PRINCIPAL CORPORATE PLACE HEADQUARTERS: OF BUSINESS OR
LEWIS BLOCK & SUPPLY COMPANY 13505 Oak Street, P.O. Box 480615 (Required)
Lewis, Dwayne 1 STREET
13505 Oak Street P.O. Box 480615
Kansas City, MO 64148 Kansas City, MO 64148
Robin Carnahan Secretary of State File Number: 200915390395
2009 ANNUAL REGISTRATION REPORT 00811990
BUSINESS Date Filed: 06/02/2009
Robin Carnahan
Secretary of State
REPORT DUE BY: 07/31/2009 ANNUAL REPORT MONTH:
April
REQUIRED INFORMATION MUST BE COMPLETE OR THE REGISTRATION REPORT WILL BE REJECTED
MAKE CHECK PAYABLE TO DIRECTOR OF REVENUE
RETURN COMPLETED REGISTRATION REPORT AND PAYMENT TO THE SECRETARY OF STATE - P.O. BOX 1366, JEFFERSON CITY, MO 65102
If changing the registered agent and/or registered office address, please check the appropriate box(es) and fill in the necessary information.
El The new registered agent
2 IF CHANGING THE REGISTERED AGENT, AN ORIGINAL WRITTEN CONSENT FROM THE NEW
REGISTERED AGENT MUST BE ATTACHED AND FILED WITH THIS REGISTRATION REPORT.
El The new registered office address
Must be a Missouri address, PO Box alone is not acceptable. This section is not applicable for Banks, Trusts and Foreign Insurance.
3 STREET/RT CITY/STATE/ZIP CITY/STATE/ZIP STREET/RT
OFFICERS BOARD OF DIRECTORS
NAME AND PHYSICAL ADDRESS (P.O. BOX ALONE NOT A NAME AND PHYSICAL ADDRESS (P.O. BOX ALONE NOT B
ACCEPTABLE). (MUST LIST PRESIDENT AND SECRETARY BELOW) ACCEPTABLE). (MUST LIST AT LEAST ONE DIRECTOR BELOW)
PRES Dwayne Edward Lewis (Required) NAME Dwayne Edward Lewis (Required)
STREET/RT 13505 Oak Street, P.O. Box 480615 STREET/RT 13505 Oak Street
CITY/STATE/ZIP Kansas City, MO 64148 WaTATE/ZIP P.O. Kansas Box City, 480615 MO 64148
V-PRES
SEC'Y Helen L Lewis (Required) NAME
STREET/RT 13505 Oak Street, P.O. Box 480615 STREET/RT
CITY/STATE/ZIP Kansas City, MO 64148 CITY/STATE/ZIP
TREAS NAME
STREET/RT STREET/RT
CITY/STATE/ZIP CITY/STATE/ZIP
NAMES AND ADDRESSES OF ALL OTHER OFFICERS AND DIRECTORS ARE ATTACHED
NAME TITLE
$65.00 If filed on or before 10/31 E-MAIL ADDRESS (OPTIONAL)
REGISTRATION REPORT FEE IS: WHEN THIS FORM IS ACCEPTED BY THE SECRETARY OF STATE,
$20.00 If filed on or before 7/31 BY LAW IT WILL BECOME A PUBLIC DOCUMENT AND ALL
INFORMATION PROVIDED IS SUBJECT TO PUBLIC DISCLOSURE
The undersigned understands that false statements made in this report are punishable for the crime of making a false
declaration under Section 575.060 RSMo. Photocopy or stamped signature not acceptable.
4 Authorized party or officer sign here Dwayne E. Lewis (Required)
Please print name and title of signer: Dwayne E. Lewis President
$35.00 If filed on or before 8/31
$50.00 If filed on or before 9/30
CITY/STATE ZIP
Kansas City,
MO
13505 Oak Street, P.O. Box 480615
64148
LEWIS BLOCK & SUPPLY COMPANY
06/02/2009
07/31/2009
200915390395
Robin Carnahan
Secretary of State
Kansas City, Kansas City, Kansas City,
MO MO MO
13505 Oak Street, P.O. Box 480615 13505 Oak Street P.O. Box 480615 13505 Oak Street, P.O. Box 480615
64148 64148 64148
Dwayne Edward Lewis Dwayne Edward Lewis Helen L Lewis
PRES SEC'Y
00811990 April
13505 Oak Street P.O. Box 480615 Kansas City, MO 64148
Lewis, Dwayne