MAGISTRATE COURT OF COUNTY, GEORGIA DATE FILED CASE NO. STATEMENTOF CLAIM vs. DESIGNATION OF AGENT FOR BUSINESS ENTITY Pursuant to O.C.G.A. 247 15-10-43(i) and Uniform Magistrate Court Rule 31, this is to certify that is a full-time employee or officer of the above-named corporation, limited liability company, sole partnership, partnership, unincorporated association or other legal entity. I have been designated by said business to represent it in the above-styled civil action. I have the authority to act of on its behalf and to bind it in the same manner as myself to any and all matters related to this case. Under penalty of perjury, signed this day of , 20Sworn to and subscribed before me This day of , 20. Deputy Clerk/Notary Public Signature Printed Name Address City, State, Zip American LegalNet, Inc. www.FormsWorkFlow.com