Free Microsoft Word - change of agent address-all entities.DOC - Connecticut

CHANGE OF AGENT'S ADDRESS
Domestic or Foreign All Entities
C.G.S. §§ 33-661; 33-927; 33-1051; 33-1217; 34-13b; 34-38p; 34-104; 34-224; 34-408; 34-429; 34-507; 34-532

[EXCEPTION $10.00 Filing Fee for Non-Stock (Non-Profit) Corporations & Limited Partnerships]
Make checks payable to "Secretary of the State"

FILING FEE: $25.00

Website Address: www.concord.sots.ct.gov Telephone Number: (860) 509-6003 Mailing Address: Connecticut Secretary of the State, Commercial Recording Division P.O. Box 150470, Hartford, CT
06115-0470

Courier Delivery Address ONLY:

(i.e. FedEx, UPS, etc.) 30 Trinity Street, Hartford, CT 06106

USE INK. COMPLETE ALL SECTIONS. PRINT OR TYPE. (Attach 8 ½ X 11 sheet if necessary) 1. Name of business entity-REQUIRED- Include business designation i.e. L.L.C., LLC, Inc, etc. (MUST MATCH OUR RECORDS EXACTLY) 2. State/Country of formation if other than Connecticut-REQUIRED, if applicable: 3. Current agent name-REQUIRED: (Print or type name of agent) Business address: (No P.O. Boxes)

Residence address: (No P.O. Boxes)

4. Execution-REQUIRED: (Subject to penalty of false statement) Print or type Name of Signatory: Capacity/Title of Signatory: Signature/Date:

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An annual report will be due yearly in the anniversary month that the entity was formed/ registered and can be easily filed online @ www.concord.sots.ct.gov Contact your tax advisor or the Taxpayer Service Center at the Department of Revenue Services as to any potential tax liability relating to your business, including questions about the Business Entity Tax. Taxpayer Service Center: (800) 382-9463 or (860) 297-5962 or go to www.ct.gov/drs

Revised 06/19/09

CHANGE OF AGENT'S ADDRESS Domestic or Foreign All Entities Filing Fee: $25.00 [EXCEPTION $10.00 Filing Fee for Non-Stock (non-Profit) Corporations & Limited Partnerships] Make checks payable to "Secretary of the State" INSTRUCTIONS 1. Name of business entity: Please provide the name of the business entity as it appears on the records of the Secretary of the State. 2. State/Country of formation: Please provide the business entitiy's state or country of formation. 3. Current agent name and new address information: This form may not be used to appoint a NEW agent. Please provide the name of the CURRENT agent. If the agent is a natural person, provide the complete street address of his or her business and CT residence. (If no business address, MUST state "NONE".) If the agent is a business entity, it must provide the address of its principal office in the block designated for "Business address" and any person signing on its behalf must include his or her title on the signature line. 4. Execution: The document must be executed/signed by an authorized official of the business entity. That person must print or type his/her name, state the capacity/title under which he/she signs and provide a signature. The execution constitutes a legal statement under the penalties of false statement that the information provided in the document is true.

Revised 9/29/08