Free 50655.PDF - Indiana

NOTICE OF CHANGE OF PRINCIPAL / OFFICER
State Form 5065 5 (R/1-03)

TODD ROKITA SECRETARY OF STATE CORPORATIONS DIVISION 302 W. Washington St., Rm. E018 Indianapolis, IN 46204 Telephone: (317) 232-6576 Indiana Code 23 -1-1-1 et seq.

INSTRUCTIONS:

Use 8 1/2" x 11" white paper for attachments. Present original and one copy to address in upper right corner of this form. Please TYPE or PRINT. Please visit our office on the web at www.sos.in.gov.

NO FILING FEE

PLEASE NOTE: INCORPORATORS CANNOT BE CHANGED.
Na me of cor poration or other entity Date of incorpo ration / orga niza tio n / r egistra tion

Cu rrent p rincipal / officer (type or prin t name)

Cu rrent p rincipal / officer addr ess (number and street, ci ty, state , ZIP code)

Ne w prin cipa l / o ffice r (type or print n ame)

Ne w prin cipa l / o ffice r a ddress (n umb er and stree t, city, state, ZIP code )

IN WITNESS WHEREOF, the undersigned executes this notice and verifies, subject to the penalties of perjury, that the statements contained herein are true, this ________________ day of ____________________________ , 20 _____ .

Sign atu re

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