STATEMENT OF CHANGE FOR REGISTERED AGENT OR OFFICE
(Per Chapter 23B, 24.03,25.15 RCW)
F O R O F F I C E U S E O N L Y
· Fill, type or print in black ink. · Checks made payable to "Secretary of State" · Sign, date and return original to:
FEE: $10.00
CORPORATIONS DIVISION 801 CAPITOL WAY SOUTH · PO BOX 40234 OLYMPIA, WA 98504-0234
*01001*
Daytime Phone Number (with area code)
IMPORTANT! Person to Contact about this Filing
Email Address
Name of Entity
UBI Number
Type of Entity (Check one box) Limited Liability Company Profit Corporation Non-profit Corporation
Changes to Registered Agent Information (Check all that apply) New Registered Agent Name Registered Office Address Change
NAME AND ADDRESS OF NEW WASHINGTON STATE REGISTERED AGENT Name (New Agent)
F O R
Street Address (Required)
City
State
WA
ZIP
O F F I C E U S E O N L Y
PO Box (Optional)
ZIP
I consent to serve as Registered Agent in the State of Washington for the above named corporation. I understand it will be my responsibility to accept Service of Process on behalf of the corporation; to forward mail to the corporation; and to immediately notify the Office of the Secretary of State if I resign or change the Registered Office Address.
Signature of Agent
Printed Name
Date
SIGNATURE (Check one box)
Registered Agent (May sign if only change is to the registered office address) LLC Member or Manager Corporate Officer or Board of Directors Chairperson
This document is hereby executed under penalities of perjury, and is, to the best of my knowledge, true and correct.
F O R
Signature
Printed Name
Date
O F F I C E U S E O N L Y 01001 (10/02)
IMPORTANT! This form must be filled out in its entirety and returned with the appropriate payment for filing.
If you have questions about the requested information on the form please contact our customer assistance at:
CUSTOMER ASSISTANCE http://secstate.wa.gov/corps/ or 360/753-7115 (TDD 360/753-1485)