PAUL D. PATE Secretary of State State of Iowa STATEMENT OF CHANGE OF REGISTERED OFFICE AND/OR REGISTERED AGENT Pursuant to Iowa law, the undersigned submits this Statement to change the business entity's registered office and/or registered agent in Iowa. Read the instructions on the back of this form before completing the information and signing below. 1. The name of the business entity is: 2. The address of the CURRENT registered OFFICE, as indicated on the Secretary of State's records is: Street Address ______________________________________________________________________________________ City State Zip 3. The address of the NEW registered OFFICE is: Street Address ______________________________________________________________________________________ City State Zip 4. The name of the CURRENT registered AGENT as indicated on the Secretary of State's records is: ______________________________________________________________________________________ (If more than one AGENT is registered, indicate which one is being replaced.) 5. The name and email address of the NEW registered AGENT is: Name _______________________________ ____________________ Email Address 6. If the REGISTERED AGENT has changed, the NEW Registered Agent must sign here, consenting to their appointment, or attach their written consent to this form. _______________________________________________ Signature of NEW Registered Agent Complete ONLY if the Registered Agent changes. 7. If the REGISTERED AGENT changes the street address of their business office on this form, the Registered Agent must sign here indicating that NOTICE of the change has been given to the business entity. _______________________________________ Signature of Registered Agent Complete ONLY if the Registered Agent changes the street address of their business office. 8. After any/all change(s) are made, the street address of the registered office and the street address of the business office of the registered agent will be identical. 9. Signature by authorized* representative: _________________________________ Date: _______________ *See instruction #9 on back PRINT Name and Title: _____________________________________________( Name and Title )__________________ Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR STATEMENT OF CHANGE OF REGISTERED OFFICE AND/OR REGISTERED AGENT All Business Entities must submit a Statement of Change form to change the Registered Office and/or Registered Agent in Iowa. It is important to read these INSTRUCTIONS before you fill out the Change form. The numbers on these instructions correspond to the numbering on the form. PLEASE PRINT LEGIBLY. 1. 2. 3. 4. 5. 6. 7. 8. Print the full name of the Business Entity. Several types of Business Entities use this same form, so include the suffix and proper punctuation. Print the street address, city, state and zip code of the CURRENT Registered Office. Print the street address, city, state and zip code of the NEW Registered Office. Print the full name of the CURRENT Registered Agent. Print the full name and email address of the NEW Registered Agent. The NEW Registered Agent, if any, must sign, consenting to their appointment, or attach a separate written consent to this form. If the Registered Agent changes the street address of their business office, they must NOTIFY the business entity and sign, indicating that NOTICE has been given. Requires no information. However, it is a required statement, and should be used as a check to verify that, after changes, the street address of the registered office and the street address of the business office of the registered agent are the same. Statement of Change form should be signed as follows. It must also state the date signed, the person's name, and the capacity in which the person signed. a. Profit, Nonprofit, and Professional Corporations:* - No fee required. By the chairperson of the board of directors, the president, or another officer of the corporation. b. Limited Liability Companies:* - No fee required. By an authorized person. c. Partnerships:* - $5.00 fee required. By two or more partners, a person authorized under Iowa Code ch. 486A, or other law. 9. d. Cooperative Associations 497, 498 and 499:* - No fee required. By the association's presiding officer of the board of directors, or the president or other officer. e. Cooperative Corporations (501) and Cooperative Associations (501A): - No fee required. By one of the cooperative's officers. * If the Business Entity is in the hands of a receiver, trustee, or other court-appointed fiduciary, by that fiduciary. NOTES: 1. One copy is to be delivered or faxed to the Secretary of State for filing. 2. The information you provide will be open to public inspection under Iowa Code chapter 22.11. SECRETARY OF STATE Business Services Division Lucas Building, 1st Floor Des Moines, Iowa 50319 Phone: (515) 281-5204 Fax: (515) 242-5953 635_0119 rev. 1/15 Website: sos.iowa.gov American LegalNet, Inc. www.FormsWorkFlow.com