Filing Fee $90.00 (If changing ONLY Item FIFTH filing fee $35.00) LIMITED LIABILITY COMPANY STATE OF MAINE STATEMENT OF CHANGE OF FOREIGN QUALIFICATION _____________________ Deputy Secretary of State _______________________________________________ (Name of the Foreign Limited Liability Company in the Jurisdiction of Organization) A True Copy When Attested By Signature _____________________ Deputy Secretary of State Pursuant to 31 MRSA §1622.3, the undersigned limited liability company executes and delivers the following Statement of Change of Foreign Qualification: FIRST: If the name of the limited liability company* in its jurisdiction of organization has been changed (If no change, so indicate), the proposed name to be used in this State: ______________________________________________________________________________________________. SECOND: If the name of the limited liability company in the jurisdiction of organization does not comply with 31 MRSA §1508, the fictitious name under which it seeks authority to conduct activities in the State of Maine is (If not applicable, so indicate) ______________________________________________________________________________________________. Form MLLC-5 accompanies this application. A fictitious name is a name adopted by a foreign limited liability company authorized to transact business in this State because its real name is unavailable pursuant to 31 MRSA §1508. THIRD: The date on which the foreign limited liability company was qualified to conduct activities in the State of Maine:_________________________________ FOURTH: The nature of the business or purpose(s) to be conducted or promoted in the State of Maine is (If no change, so indicate) ___________________________________________________________________________________________. FIFTH: The new address of the principal office, wherever located, is: (If no change, so indicate) _______________________________________________________________________________________________ (physical location - street (not P.O. Box), city, state and zip code) _______________________________________________________________________________________________ (mailing address if different from above) Form No. MLLC-12A (1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com SIXTH: Complete only if there is a change to the registered agent information. The Registered Agent is a: (select either a Commercial or Noncommercial Registered Agent) Commercial Registered Agent CRA Public Number: ____________________ __________________________________________________________________________________ (Name of commercial registered agent) Noncommercial Registered Agent __________________________________________________________________________________ (Name of noncommercial registered agent) __________________________________________________________________________________ (physical location, not P.O. Box ­ street, city, state and zip code) __________________________________________________________________________________ (mailing address if different from above) SEVENTH: Pursuant to 5 MRSA §§105.2 or 108.3, the registered agent listed above has consented to serve as the registered agent for this limited liability company. EIGHTH: The new state or other jurisdiction under whose law the foreign limited liability company is now formed (if no change, so indicate): _________________________________________________________________________________________ A certificate of existence or such other document that the Secretary of State determines to be suitable for purposes of proving the valid existence of the foreign limited liability company under the law of the State or other jurisdiction is attached. The certificate or other document must not have been issued more than 90 days before the delivery of this statement to the office of the Secretary of State. NINTH: Other changes to the statement, if any, are set forth in Exhibit______attached and made a part hereof. Dated ______________________________ ___________________________________________________ (Authorized Signature**) ___________________________________________________ (Type or print name) *The limited liability company name as used in the State of Maine must contain one of the following: "limited liability company" or "limited company" or the abbreviation "L.L.C.," "LLC," "L.C." or "LC" or, in the case of a low-profit limited liability company, "L3C" or "l3c" ­ see 31 MRSA 1508). If the addition of these words is the only difference from the limited liability company's real name in its jurisdiction of organization, then no fictitious name filing is required. **Pursuant to 31 MRSA §1676.1, this statement MUST be signed by a person authorized by the foreign limited liability company. The execution of this statement constitutes an oath or affirmation under the penalties of false swearing under 17-A MRSA §453. Please remit your payment made payable to the Maine Secretary of State. Submit completed form to: Secretary of State Division of Corporations, UCC and Commissions 101 State House Station Augusta, ME 04333-0101 Telephone Inquiries: (207) 624-7752 Email Inquiries: CEC.Corporations@Maine.gov Form No. MLLC-12A (2 of 2) Rev. 1/30/2013 American LegalNet, Inc. www.FormsWorkFlow.com Filer Contact Cover Letter To: Department of the Secretary of State Division of Corporations, UCC and Commissions 101 State House Station Augusta, ME 04333-0101 Tel. (207) 624-7752 Name of Entity (s): _______________________________________________________________________ _______________________________________________________________________ List type of filing(s) enclosed (i.e. Articles of Incorporation, Articles of Merger, Articles of Amendment, Certificate of Correction, etc.) Attach additional pages as needed. ________________________________________________________________________ ________________________________________________________________________ Special handling request(s): (check all that apply) Hold for pick up Expedited filing - 24 hour service ($50 additional filing fee per entity, per service) Expedited filing - Immediate service ($100 additional filing fee per entity, per service) Total filing fee(s) enclosed: $ ________________ Contact Information ­ questions regarding the above filing(s), please call or email: (failure to provide a contact name and telephone number or email address will result in the return of the erroneous filing (s) by the Secretary of State's office) __________