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Interim Notice Of Change Of Officer/director - Domestic And Foreign Corporations - Connecticut Secretary Of The State

INTERIM NOTICE OF CHANGE OF OFFICER/DIRECTOR

DOMESTIC AND FOREIGN CORPORATIONS

Office of the Secretary of the State

MAILING ADDRESS:

DELIVERY ADDRESS:

Commercial Recording Division

Connecticut Secretary of the State

P.O. Box 150470

30 Trinity Street

Hartford, CT 06115-0470

Hartford, CT 06106

860-509-6003

Refer to Fee Schedule for amount due.

Make Checks Payable To “Secretary of the State”

Space For Office Use Only

1. Name of Corporation:

2. New officer/director information:

(street address required - P.O. Box not acceptable)

Name

Title

Residence Address

Business Address

Check if director

3. Directors/officers who have ceased to hold office:

Name

Title

Name

Title

Check if director

Note: If additional space is needed, please reference an 8 1/2 X 11 attachment

4. EXECUTION:

Dated this _______ day of ___________, 20______.

Print or type name of signatory

Capacity of signatory

Signature

Revised 11/2007

Interim Notice Of Change Of Officer/director - Domestic And Foreign Corporations - Connecticut Secretary Of The State