Form Cr2e037b - Not-For-Profit Corporation Uniform Business Report (Ubr)
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1NOT-FOR-PROFIT CORPORATION
UNIFORM BUSINESS REPORT (UBR)
DOCUMENT #
1. Entity Name
DO NOT WRITE IN THIS SPACE
2. Principal Place of Business
3. Mailing Address
Suite, Apt. #, etc.
Suite, Apt. #, etc.
DO NOT WRITE IN THIS SPACE
City & State
City & State
Applied For
4. FEI Number
Not Applicable
Zip
Country
Zip
Country
$8.75
Additional
5. Certificate of Status Desired
Fee Required
7. Name and Address of Current Registered Agent
Name
DO NOT WRITE
Street Address (P.O. Box Number is Not Acceptable)
IN THIS SPACE
City
Zip Code
FL
8. The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both, in the state of Florida. I am familiar with, and accept
the obligations of registered agent.
SIGNATURE
SIgnature, typed or printed name of registered agent and title if applicable.
(NOTE: Registered Agent signature required when reinstating)
DATE
Make Check Payable to
FEE IS $61.25
9. Election Campaign Financing
$5.00
May Be
Trust Fund Contribution.
Florida Department of State
Initial or Amended UBR
Added to Fees
10.
OFFICERS AND DIRECTORS
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
DO NOT WRITE
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
IN THIS SPACE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
TITLE
TITLE
NAME
NAME
STREET ADDRESS
STREET ADDRESS
CITY- ST- ZIP
CITY- ST- ZIP
12. I hereby certify that the information supplied with this filing does not qualify for the exemption stated in Section 119.07(3)(i), Florida Statutes. I further certify that the information
indicated on this report or supplemental report is true and accurate and that my signature shall have the same legal effect as if made under oath; that I am an officer or director
of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 617, Florida Statutes; and that my name appears in Block 10 or on an
attachment with an address, with all other like empowered.
SIGNATURE:
SIGNATURE AND TYPED OR PRINTED NAME OF SIGNING OFFICER OR DIRECTOR
Date
Daytime Phone #
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