Free Statement of Change - Washington

STATEMENT OF CHANGE FOR REGISTERED AGENT OR OFFICE
(Per Chapter 23B, 24.03,25.15 RCW)

F O R O F F I C E U S E O N L Y

· Fill, type or print in black ink. · Checks made payable to "Secretary of State" · Sign, date and return original to:

FEE: $10.00

CORPORATIONS DIVISION 801 CAPITOL WAY SOUTH · PO BOX 40234 OLYMPIA, WA 98504-0234

*01001*
Daytime Phone Number (with area code)

IMPORTANT! Person to Contact about this Filing

Email Address

Name of Entity

UBI Number

Type of Entity (Check one box) Limited Liability Company Profit Corporation Non-profit Corporation

Changes to Registered Agent Information (Check all that apply) New Registered Agent Name Registered Office Address Change

NAME AND ADDRESS OF NEW WASHINGTON STATE REGISTERED AGENT Name (New Agent)
F O R

Street Address (Required)

City

State

WA

ZIP

O F F I C E U S E O N L Y

PO Box (Optional)

ZIP

I consent to serve as Registered Agent in the State of Washington for the above named corporation. I understand it will be my responsibility to accept Service of Process on behalf of the corporation; to forward mail to the corporation; and to immediately notify the Office of the Secretary of State if I resign or change the Registered Office Address.

Signature of Agent

Printed Name

Date

SIGNATURE (Check one box)

Registered Agent (May sign if only change is to the registered office address) LLC Member or Manager Corporate Officer or Board of Directors Chairperson

This document is hereby executed under penalities of perjury, and is, to the best of my knowledge, true and correct.
F O R

Signature

Printed Name

Date

O F F I C E U S E O N L Y 01001 (10/02)

IMPORTANT! This form must be filled out in its entirety and returned with the appropriate payment for filing.
If you have questions about the requested information on the form please contact our customer assistance at:

CUSTOMER ASSISTANCE ­ http://secstate.wa.gov/corps/ or 360/753-7115 (TDD ­ 360/753-1485)