Prepare, sign, and submit with an original signature and filing fee. This is the minimum information required. STATE OF MONTANA (This space for Secretary of State use only) STATEMENT of APPLICANT NAME CHANGE and/or ASSIGNMENT of APPLICANT for TRADEMARK or SERVICE MARK 30-13-315, MCA MAIL: LINDA McCULLOCH Secretary of State P.O. Box 202801 Helena, MT 59620-2801 (406) 444-3665 (406) 444-3976 sos.mt.gov PHONE: FAX: WEB SITE: Required Filing Fee: $20.00 per class number 24 Hour Priority Handling check box and Add $20.00 1 Hour Expedite Handling check box and Add $100.00 Make checks payable to Secretary of State. Folder ID Number: _____________ The folder number begins with a "T" and may be referenced at https://www.mtsosfilings.gov. If the document is hand written, please print legibly or the application may be denied. 1. Name and address of person/entity to whom the mark is currently registered: Name:____________________________________________________________________________________________________ __________________________________________________________________________________________________________ City: _________________________________________________ State: ____________________ Zip Code: _________________ 2. Name of mark as currently registered: __________________________________________________________________________________________________________ 3. 4. Registration number: __________________________________________Dated_________________________________________ (Month/Day/Year Name and address of new applicant/registrant: Name:____________________________________________________________________________________________________ __________________________________________________________________________________________________________ City: _________________________________________________ State: ____________________ Zip Code: _________________ 5. Applicant/registrant has acquired said mark and is one of the following (check and complete only one): An individual A firm A partnership State of organization: _____________________________________ (Attach names of general partners) A limited liability company State of organization: _______________________________________________________ A corporation State of incorporation: _________________________________________________________________ An association A union Other organization sos.mt.gov/Business/Forms 75-Applicant_Name_Change_or_Assignment_of_Application_of_Mark Revised: 09/2016 American LegalNet, Inc. www.FormsWorkFlow.com 6. I, HEREBY SWEAR AND/OR AFFIRM, under penalty of law, including criminal prosecution, that the facts contained in this document are true. __________________________________________________________________________________ Must be signed by person or entity official to whom the mark was originally issued. _____________________ Date 7. Daytime Contact: Phone_____________________________________ Email __________________________________________ sos.mt.gov/Business/Forms 75-Applicant_Name_Change_or_Assignment_of_Application_of_Mark Revised: 09/2016 American LegalNet, Inc. www.FormsWorkFlow.com