FILING FEE: $25.00 CHANGE OF AGENT Foreign (Foreign=Formed outside of Connecticut) All Entities [EXCEPTION $10.00 Filing Fee for Non-Stock (Non-Profit) Corporations & Limited Partnerships] C.G.S. §§ 33-927; 33-1217; 34-38p; 34-224; 34-408; 34-429; 34-532 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 business entity in state or country of formation-REQUIRED: The name under which the business entity transacts business in Connecticut, if different from name stated in number 1 above-REQUIRED, if applicable: 3. State/Country of formation-REQUIRED: 4. Appointment of NEW agent for service of process-REQUIRED: The business entity may not be appointed as its own agent; however a principal of the business entity residing in Connecticut may be the agent. (Check A or Complete B) EITHER A. ________ in office to be The business entity appoints the Secretary of the State of Connecticut and his/her successors its agent, upon whom any process, in any action or proceeding against it, may be served. OR B. Name of Agent (see instructions) Business address (No P.O. Boxes) ______________________________________ Signature Accepting Appointment Connecticut Residence address (No P.O. Boxes) X______________________________________ (If agent is a business also print name and title of person signing.) 5. Execution-REQUIRED: (Subject to penalty of false statement.): Print or type name: Capacity/Title: • • • Signature/Date: An annual report will be due yearly in the anniversary month that the entity was 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. 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 CONNECTICUT SECRETARY OF THE STATE 2. CHANGE OF AGENT Foreign (Foreign=Formed outside of Connecticut) All Entities C.G.S. §§ 33-927; 33-1217; 34-38p; 34-224; 34-408; 34-429; 34-532 Filing Fee: $25.00 [EXCEPTION $10.00 Filing Fee for Non-Stock Partnerships] Make checks payable to “Secretary of the State” (non-Profit) Corporations & Limited INSTRUCTIONS 1. Name of business entity in state or country of formation: name of the business entity. Please provide the complete 2. The name under which the business entity transacts business in Connecticut: Provide the complete name under which the business entity transacts business in Connecticut as it currently appears on the records of the Secretary of the State if other than the name stated in item number 1. 3. State/Country of formation: Please provide the business entity’s state or country of formation. 4. Appointment of NEW agent for service of process: The business entity may appoint either: A. The Secretary of the State or B. 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 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 4B. o Print the name & title under the signature of the individual signing acceptance on behalf of the business agent. 5. Execution: The document must be executed/signed by an authorized official of the business entity. That person must print or type their name, state the capacity/title under which they sign and provide a signature. The execution constitutes a legal statement under the penalties of false statement that the information provided in the document is true. Revised 9/29/08 American LegalNet, Inc. www.FormsWorkFlow.com