(05/17) COMMONWEALTH OF KENTUCKY ALISON LUNDERGAN GRIMES, SECRETARY OF STATE Division of Business Filings Business Filings PO Box 718, Frankfort, KY 40602 (502) 564-3490 www.sos.ky.gov Pursuant to the provisions of KRS Chapter KRS 14A and 271B, 273, 274, 275, 362 or 386 the undersigned hereby applies for an amended certificate of authority on behalf of the entity named below and, for that purpose, submits the following statements: 1. The business entity is: profit corporation (KRS 271B) nonprofit corporation (KRS 273). professional service corporation (KRS 274). business trust (KRS 386). limited liability company (KRS 275). limited partnership (KRS 362). professional limited liability company (KRS 275 statutory trust (KRS 386) limited cooperative association non-profit LLC (KRS 275). cooperative association 2. The name of the company is:. (The name must be identical to the name on record with the Secretary of State.) 3. It is an entity organized and existing under the laws of the state or country of . 4. The entity received authority to transact business in Kentucky on . 5. The entity has changed its (check all that apply) Domicile name to Name to be used in Kentucky to Jurisdiction of organization to Period of duration Form of organization Management type: Member managed Manager managed 6. This application will be effective upon filing, unless a delayed effective date and/or time is provided. The effective date or the delayed effective date cannot be prior to the date the application is filed. The date and/or time is . (Delayed effective date and/or time) Please indicate the county in which your business operates: Coun ty: . To complete the following, please shade the box complete ly. Please indicate the size of your business: Small (Fewer than 50 employees) Large (50 or more employees) Please indicate whether any of the following make up more than fifty percent (50%) of your business ownership: Women - Owned Veter an Owned Minority Owned Please indicate which of the following best describes your business: Agriculture Wholesale Trade Public Administration Other Mining Retail Trade Services Manufacturing Construction Finance, Insuranc e, Real Estate Transportation, Communications, Electric, Gas, Sanitary Services I declare under penalty of perjury under the laws of the state of Kentucky that the foregoing is true and correct. Signature of Authorized Representative Printed Name Title Date Amended Certificate of Authority FCA (Foreign Business Entity) American LegalNet, Inc. www.FormsWorkFlow.com (05/17) FILING INSTRUCTIONS APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY TYPE OF FORMATION The entity must indicate if it is a corporation (KRS 271B), a nonprofit corporation (KRS 273), a professional service corporation (KRS 274), a business trust (KRS 386), a limited liability company (KRS 275) or a limited partnership (KRS 362) by checking the appropriate box. NAME The business entity name must be exactly as written in the home state and comply with the ending requirements of KRS 14A.3-010. PRINCIPAL OFFICE ADDRESS The principal office is the office (in or out of this state) so designated in writing with the Office of the Secretary of State where the principal designated office of the business entity is located. This address is where all correspondence from the Office of the Secretary of State (See Document Delivery) will be mailed. EFFECTIVE DATE AND TIME The document will be effective on the date and time of filing, unless a delayed effective date and/or time is specified. The effective date or the delayed effective date cannot be prior to the date the application is filed. A delayed effective date may not be later than the 90th day after the date of filing. WHO MAY SIGN The document must be signed by an authorized agent. NUMBER OF COPIES If filing via mail or in person, one exact or conformed copy of the documents with the filing fee must be submitted to the address below. To make a copy of the filing for delivery to DOCUMENT DELIVERY A file stamped postcard will be sent to the principal office address. If the applicant wishes for the document to be sent to an alternate address other than the principal office, a request must be submitted in writing affirming that request. Alternate address requests must be submitted with each document filed with the Office of the Secretary of State. FILING FEE The filing fee is $40.00. Checks should be made payable to the "Kentucky State Treasurer." MAILING ADDRESS OFFICE LOCATION Alison Lundergan Grimes Room 154, Capitol Building Secretary of State 700 Capital Avenue PO Box 718 Frankfort, KY 40601 Frankfort, KY 40602-0718 Hours of Operation: 8:00 AM-4:30 PM ET CONTACT INFORMATION AND NAME AVAILABILITY If you have any questions, need additional forms or wish to search for name availability, please feel free to visit our website at www.sos.ky.gov or call (502) 564-3490. FUTURE DOCUMENTATION REQUIREMENTS AND DEADLINES The business entity must file an annual report with the Secretary of State between January 1 and June 30 of the year following the calendar year in which the corporation was formed. Subsequent annual reports must be filed with the Secretary of State between January 1 and June 30 of the following calendar years. A statement of change of the registered agent and/or registered office address or principal office address must be filed with the Secretary of State whenever a change has occurred involving any of the above categories. Downloadable forms may be found on our website. American LegalNet, Inc. www.FormsWorkFlow.com