APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY (Non-Profit Corporations) John A. Gale, Secretary of State Room 1301 State Capitol, P.O. Box 94608 Lincoln, NE 68509 http://www.sos.state.ne.us Submit in Duplicate Attach a certificate stating the name change amendment duly authenticated by the official having custody of the corporate records in the state or country under whose law it is incorporated. Such certificate shall not be more than 60 days old. Name of Corporation_____________________________________________________ Incorporated under the laws of______________________________________________ Amended Name of Corporation_____________________________________________ Date Incorporation_________________, _____ Period of Duration________________ Year Corporate Type (check one) ____ Public Benefit ____ Mutual Benefit ____ Religious Does the Corporation Have Members? ____ Yes ____ No Address of Principal Office________________________________________________ Street Address City State Zip Registered Agent________________________________________________________ Registered Office___________________________________________NE__________ Street Address and Post Office Box (if any) DATED___________________ City Zip _________________________________ Signature _________________________________ Printed Name/Title NOTE: Every filing must be signed by the chairperson of the board of directors, the president, or one of the officers of the corporation. If the corporation has not yet been formed or directors have not yet been selected, the filing shall be signed by an incorporator. If the corporation is in the hands of a receiver, trustee, or other court appointed fiduciary, the filing shall be signed by that fiduciary. FILING FEE: $15.00 Revised 7/18/2008 Neb. Rev. Stat. 21-19,149 American LegalNet, Inc. www.FormsWorkflow.com