State of California Secretary of State FILE NO._____________________________ AMENDMENT OF A JOINT POWERS AGREEMENT (Government Code section 6503.5) Instructions: 1. 2. 3. 4. Complete and mail to: Secretary of State, P.O. Box 942870, Sacramento, CA 94277-2870. Include filing fee of $1.00. Do not include attachments. A copy of the full text of the joint powers agreement and amendments, if any, must be submitted to the State Controller's office. For address information, contact the State Controller's office at www.sco.ca.gov. (Office Use Only) Date of filing initial notice with the Secretary of State:_____________________________________________________ File number of initial notice: ________________________________________________________________________ Name of the agency or entity created under the agreement and responsible for the administration of the agreement: Agency's or Entity's Mailing Address: Title of the agreement: Complete one or more boxes below. The agreement has been amended to: [ ] Change the parties to the agreement as follows: [ ] Change the name of the administering agency or entity as follows: [ ] Change the purpose of the agreement or the powers to be exercised as follows: [ ] Change the short title of the agreement as follows: [ ] Make other changes to the agreement as follows: RETURN ACKNOWLEDGMENT TO: (Type or Print) NAME ADDRESS CITY/STATE/ZIP _________________________________________ Date _________________________________________ Signature _________________________________________________ Typed Name and Title SEC/STATE NPSF 404B Rev 04/2015 American LegalNet, Inc. www.FormsWorkFlow.com