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 Statement of Consent of Registered Agent (Domestic or Foreign Business Entity) CRA __________________________________________________________________________________________ Pursuant to the provisions of KRS 14A and KRS Chapter 271B, 273, 274, 275, 362 or 386, the undersigned applicant consents to act as registered agent on behalf of the business entity named below and, for that purpose, submits the following statements: 1. The business entity is a corporation (KRS 271B, KRS 273 or KRS 274) a limited liability company (KRS 275) a limited partnership (KRS 362) a limited liability partnership (KRS 362) a business trust (KRS 386) 2. The name of the business entity is __________________________________________________________________. 3. The state or country of incorporation, organization or formation is __________________________________________. 4. The name of the initial registered agent is ____________________________________________________________. 5. The street address of the registered office address in Kentucky is: _________________________________________________ ______________ _________________________ __________________ Street Address (No Post Office Box Numbers) City State Zip Code 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) I declare under penalty of perjury under the laws of Kentucky that the forgoing is true and correct. ______________________________________ ________________________________ __________________________ Signature of Registered Agent Printed Name Title (01/12) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS STATEMENT OF CONSENT REGISTERED AGENT DOCUMENT DELIVERY All documents will be sent to the return address on the outer envelope. If no address is found, the documents will be sent to the principal office. If the applicant wishes for correspondence from the Office of the Secretary of State to be sent to someone other than those above, a request must be submitted in writing affirming that request. All other communication and notification shall follow the process prescribed in Kentucky Revised Statute. WHO MAY SIGN The document must be signed by an individual meeting one of the following requirements: � If the registered agent is an individual resident of this state, the individual must sign statement. � If registered agent is a corporation, an officer or the chairman of the board of directors must sign on behalf of the corporation. � If the registered agent is a limited liability company and management of the company vested in one or more managers, a manager must sign on behalf of the limited liability company. If management of the company is vested in its members, a member must sign. � If the registered agent is a limited partnership, a general partner must sign on behalf the limited partnership. � If the registered agent is a limited liability partnership the statement shall be executed a partner or other person authorized by chapter 362. � The representative signing the statement of consent on behalf of the business entity acting as agent must designate the title or the capacity in which he or she signs. 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. 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 the local county clerk's office, visit www.sos.ky.gov and print a copy from the organization search tool. 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. A delayed th effective date may not be later than the 90 day after the date of filing. FILING FEE There is no filing fee for filing this document. Checks should be made payable to the "Kentucky State Treasurer." MAILING ADDRESS Alison Lundergan Grimes Office of the Secretary of State PO Box 718 Frankfort, KY 40602-0718 OFFICE LOCATION Room 154, Capitol Building 700 Capital Avenue Frankfort, KY 40601 Hours of Operation: 8:00 AM-4:30 PM ET CONTACT INFORMATION If you have any questions, please feel free to visit our website at www.sos.ky.gov or call 502-564-3490. (01/12) American LegalNet, Inc. www.FormsWorkFlow.com