Fill and Sign the Fillable Online Statement of Change Designation of Form

Statement of Change / Designa�on of Agent Pg 1 | Revised 7.2018 This Box For Office Use Only STATEMENT OF CHANGE/ DESIGNATION OF REGISTERED AGENT RCW 23.95.415 □ No Filing Fee □ Expedite Service $50 CURRENT REGISTERED AGENT INFORMATION: (as currently recorded with the Office of the Secretary of State) (Optional If No Registered Agent Exists) Entity Name: ____________________________________________________________________________ UBI: ______________________________________________ ENTITY INFORMATION: Name: __________________________________________________________________________________________ Current Registered Agent Street Address (required) (Must be a physical address No PO Box or PMB) Current Registered Agent Mailing Address (optional) □ Check if mailing address is the same as street address Country : United States State : Washington Address : ______________________________________ _______________________________________________ Zip : __________ City: ___________________________ Country: United States State : Washington Address : ______________________________________ _______________________________________________ Zip : __________ City: ___________________________ Provide new Registered Agent information on Page 2 This record is hereby executed under penalties of perjury, and is, to the best of my knowledge, true and correct. _______________________________________ __________________________________ ____________________ Signature Printed Name/Title Date AUTHORIZED PERSON: (360) 725 - 0377 | www.sos.wa.gov/corps 801 Capitol Way S, Olympia, WA 98504 -0234 Statement of Change / Designa�on of Agent Pg 1 | Revised 7.2018 NEW REGISTERED AGENT: Please complete ONE type of Registered Agent below, be sure to include the name below the checked box. Then continue to provide the required street address. Mailing address if needed. Phone: ________________________ Email: _________________________________________ CONSENT TO SERVE AS REGISTERED AGENT - REQUIRED FOR ALL TYPES I hereby consent to serve as Registered Agent in the State of Washington for the named entity. I understand it will be my responsibility to accept service of process, notices, and demands on behalf of the entity; to forward mail to the entity; and to immediately notify the Office of the Secretary of State if I resign or change the Registered Office Address. __________________________________ _________________________________ ____________________ Signature of Registered Agent Printed Name/Title Date Country : United States State : Washington Address : ______________________________________ _______________________________________________ Zip : __________ City: ___________________________ Country: United States State : Washington Address : ______________________________________ _______________________________________________ Zip : __________ City: ___________________________ Registered Agent Mailing Address (optional) □ Check if mailing address is the same as street address Registered Agent Street Address (required) (Must be a physical address No PO Box or PMB) □ Office or Position ___________________________ List the Office or Position serves as agent. (Only if using the specific office or position as the registered agent, no matter who holds the position like: Secretary, Member or Treasurer.) □ Entity ____________________________ Name of a Non -commercial Registered Agent. (Any business not registered as a Commercial Registered Agent.) □ Individual _____________________________ First and last name of a Non -commercial Registered Agent. (Any person not registered as a Commercial Registered Agent.) Is the Registered Agent a Commercial Registered Agent? □ Yes □ No If Yes , pr ovid e t h e n am e of t he C omm er cial Register ed Agent : __________________________________ A Commercial Registered Agent is an entity or individual that is registered with the Office of the Secretary of State to receive legal documents on behalf of a corporation. A Commercial Registered Agent has the entities /individual’s address on record with the office. A Registered Agent consent is still required for a Commercial Registered Agent located below. If No , plea se cont in ue b elow