JAMES C. KIRKPATRICK STATE INFORMATION CENTER JASON KANDER SECRETARY OF STATE STATE OF MISSOURI CORPORATIONS (866) 223-6535 INSTRUCTIONS FOR CERTIFICATE OF CHANGE OF OWNER'S NAME FOR TRADEMARK/SERVICE MARK 1. Provide the name and address of the person or business entity who originally registered the mark. 2. Provide the Missouri Registration Number from the Certificate of Registration and the original date of registration. 3. Provide the new name of the registrant (individual or business entity). 4. The form is to be signed by the officer or authorized party of the registrant. 5. The change of name form is to be notarized. The notary public is to sign the form and also include their embossed or rubber stamp seal on the document. Any additional notary information required by state law is also to be completed by the notary public. 6. The fee for a change of name of a trademark/service mark is $55. All checks or money orders should be made payable to the Director of Revenue. 7. Send a separate form and check for each change of name application or mark. 8. A certificate will be issued in the new name of the officer or authorized party of the registrant for the remainder of the term of registration. It will be mailed to the officer or authorized party unless otherwise specified. 9. Completed change of name forms and fee should be returned to the Secretary of State's Office, Corporations, PO Box 778, Jefferson City, MO 65102-0778. 10. If you have any questions regarding the completion of this form, please call our office at (866) 223-6535. TMSM 40A (06/2012) James C. Kirkpatrick State Information Center 600 W. Main Street · Jefferson City 65101 Administrative Rules · Business Services · Elections · Publications · Securities · State Archives · State Library · Wolfner Library American LegalNet, Inc. www.FormsWorkFlow.com State of Missouri D WE S T ITE D AN DIV Jason Kander, Secretary of State X ESTO LE ED WE FA ID E PLURIB M UNU SALUS PO MDC PUL I SUPREM CCXX This is to certify that (Original Name of Registrant) of (Address) has changed its name, and that its use of, right to, and interest in the mark which is registered in the State of Missouri, Registration No. , dated , shall hereafter be in the name of (New Name of Registrant) for the remainder of the term of the registration or of the last renewal thereof. By the signature below, the registrant hereby acknowledges and represents that it has filed all filings and/or amendments with the Missouri Secretary of State necessary to effect the referenced name change, and agrees that this change of name does not serve as or complete an assignment of rights to a different entity or owner. State of County of (Date) On this day of , before me personally appeared , being the person who signed this instrument, who acknowledged that he/she signed it as a free act on his/her own behalf (or on behalf of the identified corporation or other juristic entity with authority to do so). Return completed form to: Corporations Section PO Box 778 Jefferson City, MO 65102-0778 (866) 223-6535 LL US A Corporations Section PO Box 778 / 600 W. Main St., Rm. 322 Jefferson City, MO 65102-0778 Toll-Free (866) 223-6535 UN Certificate of Change of Owner's Name For Trademarks and Service Marks (Signature of officer or authorized party of the registrant) (Title) (Signature of Notary Public) Typed or printed name State of Commissioned for My Commission Expires Commission # County TMSM 40 (06/2012) American LegalNet, Inc. www.FormsWorkFlow.com