CHANGE OF AGENT Domestic (Domestic=Formed in Connecticut) All Entities C.G.S. §§ 33-661; 33-1051; 34-13b; 34-104; 34-408; 34-507 FILING FEE: $25.00 [EXCEPTION $10.00 Filing Fee for Non-Stock (Non-Profit) Corporations & Limited Partnerships] Make checks payable to “Secretary of the State” Website Address: www.concord.sots.ct.gov Telephone Number: (860) 509-6003 Mailing Address: Connecticut Secretary of the State, Commercial Recording Division P.O. Box 150470, Hartford, CT Courier Delivery Address ONLY: (i.e. FedEx, UPS, etc.) 30 Trinity Street, Hartford, CT 06106 06115-0470 USE INK. COMPLETE ALL SECTIONS. PRINT OR TYPE. (Attach 8 ½ X 11 sheet if necessary) 1. Name of entity-REQUIRED: (MUST MATCH OUR RECORDS EXACTLY. Include business designation i.e. L.L.C., LLC, Inc, etc.) 2. Appointment of new agent-REQUIRED: Complete A or B, not both CONNECTICUT SECRETARY OF THE STATE EITHER A. If agent is an individual: Print or type full legal name: Business Address: (No P.O. Box) If none, MUST state “NONE” Signature accepting appointment: CT Residence Address: (No P.O. Box) X OR B. If agent is a business: Print or type name of business as it appears on our records: CT Business Address: (No P.O. Box) Signature accepting appointment on behalf of agent: Print name & title: X 3. Execution-REQUIRED: (Subject to penalty of false statement) Capacity/Title: Print or type name: Signature/Date: • An annual report will be due yearly in the anniversary month that the LLC was formed/registered and can be easily filed online @ www.concord.sots.ct.gov • Contact your tax advisor or the Taxpayer Service Center at the Department of Revenue Services as to any potential tax liability relating to your business, including questions about the Business Entity Tax. Terminating business in Connecticut requires you to file a dissolution/cancellation/withdrawal form pertinent to your entity with this office. • Taxpayer Service Center: (800) 382-9463 or (860) 297-5962 or go to www.ct.gov/drs Revised 06/19/09 American LegalNet, Inc. www.FormsWorkFlow.com CHANGE OF AGENT Domestic (Domestic=Formed in Connecticut) All Entities C.G.S. §§ 33-661; 33-1051; 34-13b; 34-104; 34-408; 34-507 Filing Fee: $25.00 [EXCEPTION $10.00 Filing Fee for Non-Stock (non-Profit) Corporations & Limited partnerships] Make checks payable to “Secretary of the State” INSTRUCTIONS 1. Name of entity: Please provide the complete name of the business entity, as it appears on the records of The Secretary of the State. Include business designation i.e. LLC, Inc, etc. (MUST MATCH OUR RECORDS EXACTLY) 2. Appointment of new agent: The business entity may appoint either: A. Any individual who is a resident of Connecticut, including a principal of the business entity. (An individual must provide the complete street address of his or her business and a Connecticut residence address. If none, MUST state “NONE”) or B. Any of the following business types, on record with this office: • A Connecticut corporation, limited liability company, limited liability partnership or statutory trust • A foreign corporation, limited liability company, limited liability partnership or statutory trust, which has obtained a certificate of authority to transact business in Connecticut and has a Connecticut address on file with this office o The business must provide a Connecticut business address in Box 2B. o Print the name & title under the signature of the individual signing acceptance on behalf of the business agent. 3. Execution: The document must be executed/signed by an authorized official of the business entity. That person must print or type his or her full legal name, state the capacity/title under which he/she signs and provide his/her signature. The execution constitutes a legal statement under the penalties of false statement that the information provided in the document is true. Revised 9/23/08 American LegalNet, Inc. www.FormsWorkFlow.com