08-469 Rev 7/1/16 D Coop Statement of Change 1 of 2 Domestic Cooperative (AS 10.15) This Statement of Change form for Registered Agents or Registered Agent Address Changes is only forDomestic Cooperatives. The Statement of Change will not be filed if the official signing this form does not match an official onrecord for this entity and/or if your entity222s biennial report is not current. To verify your entity information onrecord, go online to Corporations.Alaska.Gov, Search Corporations Database Standard processing time for complete and correct filings submitted to this office is approximately 10-15business days. All filings are reviewed in the date order they are received. The information you submit is a public record and will be posted on the State222s website. COR Corporations Section State Office Building, 333 Willoughby Avenue, 9th Floor PO Box 110806, Juneau, AK 99811-0806 Phone: (907) 465-2550 Fax: (907) 465-2974 Email: corporations@alaska.gov Website: Corporations.Alaska.Gov Statement of Change 1. Important: AS 10.15.025-.35 Per AS 10.15.025, each Domestic Cooperative shall (must) continuously (without interruption) maintain in this state (Alaska) a registered agent AND a registered office (with an Alaskan physical location and an Alaskan mailing address) for the purpose of a registered agent222s statutory requirements to receive service of processes, notices, or demands required or permitted by law to be served upon the cooperative. Failure to meet registered agent requirements could result in involuntary dissolution of the entity222s authority to transact business in the State of Alaska. For more registered agent information go to Corporations.Alaska.Gov, Registered Agents FAQs. 2. Fee: $25 Nonrefundable Filing Fee (CORF) 3 AAC 16.040(c) Mail this form and the non-refundable $25 filing fee in U.S. dollars to the letterhead address. Make the check or money order payable to the State of Alaska, or use the attached credit card payment form. 3. Entity Information on Record with the State: AS 10.15.030 and AS 10.06.165(a)(1) Entity Name: Alaska Entity Number: FOR DIVISION USE ONLY T HE S TATE ALASKA of Department of Commerce, Community and Economic Development Division of Corporations, Business and Professional Licensing American LegalNet, Inc. www.FormsWorkFlow.com 08-469 Rev 7/1/16 D Coop Statement of Change 2 of 2 4. PREVIOUS Registered Agent Information on Record with the State: AS 10. 1 5 . 0 30 , and AS 10. 06 . 165 (a) (2), (4) PREVIOUS Registered Agent Name: PREVIOUS Registered Agent Addresses: PHYSICAL Address: City: State: AK (mandatory) ZIP Code: MAILING Address: City: State: AK (mandatory) ZIP Code: 5. NEW Registered Agent Information to be Updated with the State: AS 10. 1 5 . 0 30 , and AS 10. 06 . 165 (a) (3), (5) NEW Registered Agent Name: (Registered agent cannot be the entity listed in Item 3 on Page 1 and cannot be an LLC.) If the new Registered Agent is an entity, provide its entity number: NEW Registered Agent Addresses: PHYSICAL Address: City: State: AK (mandatory) ZIP Code: MAILING Address: City: State: AK (mandatory) ZIP Code: 6. Authorization per Alaska Statute: AS 10.15.030 and AS 10.06.165(a)(6) The registered agent change was authorized by a resolution duly adopted by the board of directors of this cooperative. Per AS 10.15.315, the domestic cooperative is to keep and make available the record of the resolution. 7. Required Signature: AS 10.15.030 and AS 10.06.165(a) The Statement of Change must be signed by the corporate president or vice president currently on record. Persons who sign documents filed with the commissioner that are known to the person to be false in material respects are guilty of a class A misdemeanor. Signature: Date: Printed Name: Title of Authorized Signer: President 227 or 227 Vice-President American LegalNet, Inc. www.FormsWorkFlow.com 08-561 Rev 7/14/16 Contact Information Return this form with your filing This information may be used by the Division to assist with processing your attached filings This form will not be filed for record, or appear online COR Corporations Section State Office Building, 333 Willoughby Avenue, 9th Floor PO Box 110806, Juneau, AK 99811-0806 Phone: (907) 465-2550 Fax: (907) 465-2974 Email: corporations@alaska.gov Website: Corporations.Alaska.Gov Contact Information Entity Information Enter your entity information as it appears on this filing. Entity Name: AK Entity #: Contact Person Whom may we contact with any questions or problems with this filing? Company: Contact: Mailing Address: Address: City: State: ZIP: Phone: Email: Document Return Address Provide an address for the return of your filed documents. Return my filings to the address provided ABOVE Return my filings to this address provided BELOW Company: Contact: Mailing Address: Address: City: State: ZIP: FOR DIVISION USE ONLY T HE S TATE ALASKA of Department of Commerce, Community and Economic Development Division of Corporations, Business and Professional Licensing American LegalNet, Inc. www.FormsWorkFlow.com All major credit cards are accepted. For security purposes, do not email credit card information. Include this credit card payment form with your application. Name of Applicant or Licensee: Program Type: License Number (if applicable): I wish to make payment by credit card for the following (check all that apply): AMOUNT Application Fee: License or Renewal Fee: Other (name change, wall certificate, fine, duplicate license, exam, etc.): 1. 2. TOTAL: Name (as shown on credit card): Mailing Address: Phone Number: Email (optional): Signature of Credit Card Holder: 08-4438 Rev 12/26/18 Credit Card Payment Form (all major cards accepted) State of Alaska Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing PO Box 110806, Juneau, AK 99811 Phone: (907) 465-2550 Credit Card Payment Form CREDIT CARD INFO: Your payment cannot be processed unless all fields are completed! All four fields MUST be completed! This section will be destroyed after the payment is processed. 1. Account Number : 2. Expiration Date: 3. Billing ZIP Code: 4 . Security Code : FOR DIVISION USE ONLY T HE S TATE ALASKA of Department of Commerce, Community , and Economic Development Division of Corporations, Business and Professional Licensing American LegalNet, Inc. www.FormsWorkFlow.com