Wyoming Secretary of State State Capitol Building, Room 110 200 West 24th Street Cheyenne, WY 82002-0020 Ph. 307.777.7311 Fax 307.777.5339 Email: business@state.wy.us For Office Use Only Statutory Trust Certificate of Trust 1. Name of the statutory trust: 2. Name and address of at least one (1) of the trustees authorized to manage the statutory trust: 3. Name and physical address of its registered agent: (The registered agent may be an individual resident in Wyoming, a domestic or foreign entity authorized to transact business in Wyoming, having a business office identical with such registered office. The registered agent must have a physical address in Wyoming. A Post Office Box or Drop Box is not acceptable. If the registered office includes a suite number, it must be included in the registered office address.) 4. Mailing address of the statutory trust: 5. Principal office address: 6. Future effective date or time of this certificate if it is NOT to be effective upon the filing of this certificate: (Date – mm/dd/yyyy) ST-CertificateTrust - Revised 08/13/2009 American LegalNet, Inc. www.FormsWorkFlow.com 7. Execution: Trustee Signature: _________________________________________ Date: (mm/dd/yyyy) Print Name: Trustee Signature: _________________________________________ Date: (mm/dd/yyyy) Print Name: Trustee Signature: _________________________________________ Date: (mm/dd/yyyy) Print Name: Contact Person: Daytime Phone Number: Email: Checklist Filing Fee: $100.00 Make check or money order payable to Wyoming Secretary of State. The Certificate of Trust must be signed by at least one trustee. The Certificate of Trust must be accompanied by a written consent to appointment executed by the registered agent. For consistency the Secretary of State’s Office will only keep one version of the agent’s name on file. Please submit one originally signed document and one exact photocopy of the filing. 10 Please review form prior to submitting to the Secretary of State to ensure all areas have been completed to avoid a delay in the processing of your documents. Other Requirements: An annual report will be due on or before January 1 each year. If not paid within thirty (30) days from the due date, the entity will be subject to dissolution/revocation. ST-CertificateTrust - Revised 08/13/2009 American LegalNet, Inc. www.FormsWorkFlow.com Wyoming Secretary of State State Capitol Building, Room 110 200 West 24th Street Cheyenne, WY 82002-0020 Ph. 307.777.7311 Fax 307.777.5339 Email: business@state.wy.us Consent to Appointment by Registered Agent I, , registered office located at (name of registered agent) voluntarily consent to serve * (registered office physical address, city, state & zip) as the registered agent for (name of business entity) I hereby certify that I am in compliance with the requirements of W.S. 17-28-101 through W.S. 17-28-111. Signature:__________________________________________ Date: (Shall be executed by the registered agent.) Print Name: Daytime Phone: Title: (mm/dd/yyyy) Email: Registered Agent Mailing Address (if different than above): *If this is a new address, complete the following: Previous Registered Office(s): I hereby certify that:  After the changes are made, the street address of my registered office and business office will be identical.  This change affects every entity served by me and I have notified each entity of the registered office change.  I certify that the above information is correct and I am in compliance with the requirements of W.S. 17-28-101 through W.S. 17-28-111. Signature: __________________________________________ Date: (Shall be executed by the registered agent.) (mm/dd/yyyy) Checklist Submit one originally signed consent to appointment and one exact photocopy. RAConsent – Revised 10/21/2009 American LegalNet, Inc. www.FormsWorkFlow.com