Free c156ds503s1509950c11323.indd - Massachusetts

DF PC

The Commonwealth of Massachusetts
William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

FORM MUST BE TYPED

(General Laws Chapter 156D, Section 5.03 and Section 15.09; 950 CMR 113.23)
Name of registered agent: ________________________________________________________________________________

Statement of Resignation of Registered Agent

FORM MUST BE TYPED

Exact name of corporation: ______________________________________________________________________________ Current registered office address: __________________________________________________________________________ (number, street, city or town, state, zip code) The above named registered agent hereby resigns his appointment as registered agent of the corporation. The registered office address will: (Check appropriate box) ® also be discontinued. ® remain the same.

It is hereby certified that a copy of this statement of resignation shall be furnished to the corporation pursuant to G. L. Chapter 156D, Section 5.03 and Section 15.09. The appointment is terminated, and the registered office discontinued, if so provided, on the thirty-first day after the date on which the statement is filed, unless a later effective date not more than 90 days from the date and time of filing is specified: ____________________________________________________________________________________________

Signed by: ___________________________________________________________________________________________ , (signature of registered agent)

on this ___________________________________ day of ______________________________of ____________________ .

c156ds503s1509950c11323 01/13/05

COMMONWEALTH OF MASSACHUSETTS
Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

William Francis Galvin

(General Laws Chapter 156D, Section 5.03 and Section 15.09; 950 CMR 113.23)

Statement of Resignation of Registered Agent

I hereby certify that upon examination of this statement of resignation, duly submitted to me, it appears that the provisions of the General Laws relative to the organization of corporations have been complied with, and I hereby approve said statement; and the filing fee in the amount of $_____having been paid, said statement is deemed to have been filed with me this _____________ day of _____________, 20______ , at _______a.m./p.m. time Effective date: _________________________________________________ (must be within 90 days of date submitted)

WILLIAM FRANCIS GALVIN
Secretary of the Commonwealth

Filing fee: $25 for paper or fax filings. No fee if filed electronically.

TO BE FILLED IN BY CORPORATION
Contact Information: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Telephone: ___________________________________________________ Email: ______________________________________________________ Upon filing, a copy of this filing will be available at www.sec.state.ma.us/cor. If the document is rejected, a copy of the rejection sheet and rejected document will be available in the rejected queue.