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 Resignation of Registered Agent (Domestic or Foreign Business Entity) SRA __________________________________________________________________________________________ Pursuant to the provisions of KRS Chapter 14A and 271B, 273, 274, 275, 362 or 386, the undersigned applies for resignation of registered agent and, for that purpose, submits the following statements: 1. I, ____________________________________________________________________________________, do hereby resign as registered agent; and/or discontinue the registered office address 2. The business entity which I am resigning from is_______________________________________________________, (The name must be identical to the name on record with the Secretary of State.) 3. The business 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); or a business trust (KRS 386) 4. The business entity was organized and existing in the state or country of __________________________________. 5. The mailing address of the resigning agent: _________________________________________________________________________________________________ Street Address or Post Office Box Numbers City State Zip 6. The agency appointment shall be terminated and the registered office discontinued, if so provided, on the 31 day after the date on which the statement is filed. I declare under penalty of perjury under the laws of Kentucky that the forgoing is true and correct. __________________________________________________________________________________________________ Signature of Registered Agent Printed Name Date st (01/12) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS STATEMENT OF RESIGNATION OF REGISTERED AGENT NAME Use the exact name of the business entity as registered on file with the Office of the Secretary of State. 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. 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. DELAYED 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 th 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 90 day after the date of filing. WHO MAY SIGN The document must be signed by the registered 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 ad dress 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. FILING FEE There is no filing fee for filing this document. MAILING ADDRESS Alison Lundergan Grimes Office of the Secretary of State P.O. 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