F0010 - Page 1 of 2
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1333
*0010-1-2*
1. Corporate ID
Registered Agent/Office Statement of Change Profit Corporation
2. Corporate Name
3. Federal Tax ID
4. Name and Street Address of the Registered Agent and Registered Office (as on file with the Secretary of State) Name Physical Address P.O. Box City, State, ZIP5, ZIP4 5. New Registered Agent's Name and Registered Office
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Physical Address P.O. Box City, State, ZIP5, ZIP4
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Rev. 01/96
F0010 - Page 2 of 2
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1333
*0010-2-2*
Registered Agent/Office Statement of Change Profit Corporation
6. If agent has changed, mark appropriate box
6A: The undersigned hereby accepts designation as registered agent for service of process Signature of Registered Agent
(Please keep writing within block)
OR
6B: Statement of written consent is attached, signed by the new registered agent
7. The Corporation has been notified of the change of registered office. Yes By: Signature No (Please keep writing within block)
Printed Name
Title
Filing Fee: $10.00
Rev. 01/96