APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY (Non-Profit Corporations) , Secretary of State P.O. Box 94608 Lincoln, NE 68509 002www.sos.ne 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 OfficeNE Street Address and Post Office Box (if any) City Zip Effective date if other than the date filed 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: $10.00 plus $5.00 per page for attachments & for the certificate (if required) Revised /201 Neb. Rev. Stat. 21-19,149 American LegalNet, Inc. www.FormsWorkFlow.com