Free 635_0987.p65 - Iowa

MICHAEL A. MAURO Secretary of State State of Iowa

STATEMENT OF RESIGNATION OF REGISTERED AGENT

Read the instructions on the reverse before completing. All items must be completed before the statement of resignation will be considered.

Statement
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Name of Business Entity: _____________________________________________________________________
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Principal Office Address: ______________________________________________________________________
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Registered Office Address: ____________________________________________________________________

TO THE ABOVE NAMED BUSINESS ENTITY. Please be advised that notice is hereby given to said business entity
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that I, ______________________________________, registered agent appearing on the records of the secretary of
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state for the business entity, do hereby resign as the registered agent effective ______________________. The
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registered office of the business entity_ _

is __

is not discontinued at the same time.

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Signature of Registered Agent: ___________________________________________________
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Date: ___________________________

Certificate of Mailing
1 2

I, _________________________________, registered agent for ____________________________________________,
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appearing on the records of the secretary of state, hereby certifies that on _____________________ I did send a copy of
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this Statement of Resignation of Registered Agent by certified mail to the business entity
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at the above principal place

of business and

to the above registered office, if the office was not discontinued.
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Signature of Registered Agent: __________________________________________________
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Date: ___________________________

635_0987 rev. 04/07

INSTRUCTIONS
Read the instructions before completing. All items must be completed before the application will be considered. Please print or type the information required unless a signature is specified. If you are uncertain about the accuracy of any of the required information, contact the Secretary of State's Office, at (515) 281-5204 for assistance. Each item number below corresponds to the same number as they appear on the Statement or Certificate of Mailing.

Statement
1. Insert the complete legal name of the business entity. 2. Insert the address of the business entity's principal place of business. 3. Insert the address of the registered office. 4. Insert your name. 5. State the date on which the resignation shall become effective. 6. Place an "X" in the appropriate box to indicate whether the registered office is also being discontinued. 7. Sign the statement. 8. Insert the date the statement was signed.

Certificate of Mailing
1. Insert your name. 2. Insert the complete legal name of the business entity. 3. Insert the date the statement was mailed to the business entity. 4. Place an "X" in the box to indicate that the statement was sent to the business entity's principal office. 5. Place an "X" in the box to indicate that the statement was sent to the registered office if the registered office is not being discontinued. 6. Sign the certification. 7. Insert the date the certification was signed.

NOTES: 1. There is no filing fee. 2. The information you provide will be open to public inspection under Iowa Code chapter 22.11.

SECRETARY OF STATE Business Services Division Lucas Building, 1st Floor Des Moines, IA 50319 Phone: (515) 281-5204 FAX: (515) 242-5953 or (515) 281-7142 Website: www.sos.state.ia.us