L-122 (4/94) New Jersey Division of Revenue Certificate of Change - Registered Name or Address, or Both ( For Use by a Limited Liability Company) This form may be used by domestic and foreign Limited Liability Companies to change an agent name or address or both. If a P.O. box is used for registered address, the street address must be included. Return this form with a $25.00 check made out to: Treasurer, State of New Jersey. Write the LLC number on the top left of your check. LLC Name and Number: State of Original Filing: IMPORTANT - INCLUDE INFORMATION ON BOTH THE PRIOR & NEW AGENT Prior Agent: Name Street Address City New Agent: Name Street.Address City State Zip State Zip ______________________________________ Signature of Registered Agent ______________ Date NJ Division of Revenue, PO Box 308, Trenton, NJ 08646 American LegalNet, Inc. www.USCourtForms.com Rev 7/18/05 Instructions for Form L-122 CERTIFICATE OF CHANGE OF REGISTERED AGENT/ADDRESS OR BOTH, For LIMITED LIABILITY COMPANIES (Title 42:2B) STATUTORY FEE: $25 The MANDATORY fields are: Business Name/Number List the name and ten-digit business ID as they appear on the records of the State Treasurer. Prior Agent Name List the current agent name as it appears on the records of the State Treasurer. Prior Agent Office List the current agent office as it appears on the records of the State Treasurer. New Agent Name If you are changing the registered agent, list the new name; otherwise, leave this field blank. New Office If you are changing the registered office, list the new address; otherwise, leave this field blank. Provide a New Jersey street address. A PO box may be used only if the street address is listed as well. EXECUTION (DATE/SIGNATURE) Have an authorized representative or the current registered agent sign. Also, list the date of execution (signature). ************ These documents should be filed in duplicate. Non-profits should file in triplicate. Make checks payable to: TREASURER, STATE of NEW JERSEY. (No cash, please) Mail to: NJ Division of Revenue, PO Box 308, Trenton, NJ 08646 American LegalNet, Inc. www.USCourtForms.com