Wyoming Secretary of State
State Capitol Building, Room 110 200 West 24th Street Cheyenne, WY 82002-0020 Ph. 307.777.7311 Fax 307.777.5339 Email: email@example.com
For Office Use Only
Statement of Change of Registered Agent's Name and/or Registered Office By Registered Agent
1. This change affects every entity that I represent. OR This change affects only the entities on the attached list.
2. Name of its current registered agent and street address of its current registered office: Current Registered Agent: Current Registered Office: 3. Name of its new registered agent (if applicable) and street address of its new registered office (if applicable): New Registered Agent:
For consistency the Secretary of State's Office will only keep one version of the agent's name on file.
New Registered Office:
4. I hereby certify that I am in compliance with all requirements of W.S. 17-28-101 through W.S. 17-28-111. 5. After the changes are made, the street address of its registered office and the business office of its registered agent will be identical. 6. I hereby certify that every entity listed on the attached list has been notified of the registered agent name/registered office change. 7. I voluntarily consent to serve as the registered agent for every entity listed on the attached list. 8. A separate notice must be provided by the entity to change the mailing and/or principal office address. Date:
Signature: _______________________________________________ (Shall be executed by the registered agent.) Print Name: Title:
Contact Person: Daytime Phone Number: Email:
Checklist If you are a Commercial Registered Agent, changes noted on this form shall also be reflected on your Commercial Registered Agent form. Filing Fee: Nonprofit Corporation - $3.00 (by statute); All other business entities - No Fee Please submit one originally signed document and one exact photocopy of the filing. Please review form prior to submitting to the Secretary of State to ensure all areas have been completed to avoid a delay in the processing of your documents. RA-RO ChangeByRA 2/25/2009