ROSS MILLER Secretary of State 204 North Carson Street, Suite 1 Carson City, Nevada 89701-4520 (775) 684 5708 Website: www.nvsos.gov
(PURSUANT TO NRS 80.030)
USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY
Officer's Statement (Pursuant to NRS 80.030) 1. Name of corporation: (provide modified name also if filed pursuant to NRS 80.025)
name currently on file in Nevada
name in home state, if using modified name in Nevada
2. State of incorporation: 3. Changes reflected by filing of document: (check the appropriate spaces and/or describe under "other")
Name Stock Purpose Dissolution Merger Other: (specify changes)
4. Signature of officer making statement: (must be signed by an officer of the corporation)
Signature of Officer Title
* Submit this form with either a certified copy of or a certificate evidencing the filing of any document, amendatory or otherwise, relating to the original articles in the place of the corporations creation.
IMPORTANT: Failure to include any of the above information and submit with the proper fees may cause this filing to be rejected.
This form must be accompanied by appropriate fees.
Nevada Secretary of State Officers Statement Revised: 3-12-09