Statement of Change Registered Agent or Office This Box For Office Use Only Page 1 of 2 See attached detailed instructions □ No Fee for Standard Service □ Expedited Service $50.00 UBI Number: STATEMENT OF CHANGE FOR REGISTERED AGENT/OFFICE Chapter 23B, 24.03, 25 RCW SECTION 1 NAME OF ENTITY: (as currently recorded with the Office of the Secretary of State) SECTION 2 (select the entity type that applies) □ Limited Liability Company (LLC) □ Limited Partnership (LP) □ Profit Corporation □ Non-profit Corporation □ Limited Liability Partnership (LLP) SECTION 3 (CURRENT) NAME AND ADDRESS OF THE WASHINGTON STATE REGISTERED AGENT: Name: ____________________________________________________________________________ Physical Location Address (required): ______________________________________________________________ City _____________________________________________ WA Zip Code ____________ Mailing or Postal Address (optional): _______________________________________________________________ City _____________________________________________ WA Zip Code _____________ Statement of Change Washington Secretary of State Revised 07/10 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 SECTION 4 (NEW) NAME AND ADDRESS OF THE WASHINGTON STATE REGISTERED AGENT: Name: ____________________________________________________________________________ Physical Location Address (required): ______________________________________________________________ City _____________________________________________ WA Zip Code ____________ Mailing or Postal Address (optional): _______________________________________________________________ City _____________________________________________ WA Zip Code _____________ CONSENT TO SERVE AS REGISTERED AGENT: I consent to serve as Registered Agent in the State of Washington for the above named entity. I understand it will be my responsibility to accept Service of Process on behalf of the entity; to forward mail to the entity; and to immediately notify the Office of the Secretary of State if I resign or change the Registered Office Address. X___________________________________________________________________________ Signature of New Registered Agent Printed Name Date SECTION 5 AUTHORIZED SIGNATURE (check one) □ Registered Agent only if change is to registered office address □ LLC Member/Manager □ Corporate Officer/Board Chairperson □ General Partner This document is hereby executed under penalties of perjury, and is, to the best of my knowledge, true and correct. X __________________________________________________________________________ Signature Printed Name & Title Date Phone Statement of Change Washington Secretary of State Revised 07/10 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS – STATEMENT OF CHANGE Please complete all sections of the Statement of Change form. USE DARK INK ONLY. For an electronic, fillable version of this form, please visit our website at www.sos.wa.gov/corps UBI Number: If available, please enter your existing Unified Business Identifier (UBI Number) as currently recorded with the Office of the Secretary of State, in the box in the upper right hand corner of page 1. Section 1 Indicate the entity name as it is currently recorded with the Office of the Secretary of State. Section 2 Indicate the entity type for the Statement of Change. (select only one option) Section 3 Provide the current registered agent as recorded with the Office of the Secretary of State. Section 4 Provide the NEW registered agent in Washington State. The registered agent may be an individual who is a resident of Washington State, or a business entity registered with the Secretary of State’s office. The agent must have a physical address in Washington State where they can be located. An alternative mailing address may be used in addition to the physical address. The mailing address must also be in Washington State. The registered agent must print their name and sign the consent to serve as registered agent Section 5 Select the authorized title of the person submitting the Statement of Change. The person signing will provide their signature, printed name and title, the date signed, and phone number. If you are unsure that you have authority to sign this Statement of Change then please review state requirements for the type of entity requested or consult our office at 360-725-0377 for requirements. Additional Information: FEES: There is no filing fee for standard service. If expedited service is requested, include an additional $50.00 and write “EXPEDITE” on the outside of the envelope. Make the checks or money orders payable to “Secretary of State”. (All filing fees are non-refundable) Mail completed forms and payment to: Secretary of State Corporation Division 801 Capitol Way S PO Box 40234 Olympia WA 98504-0234 If you have questions, need assistance or would like to provide feedback please visit the Corporations Division website at www.sos.wa.gov/corps or call 360-725-0377. Statement of Change Washington Secretary of State Revised 07/10 American LegalNet, Inc. www.FormsWorkFlow.com