Form Ssc-109 - Statement Of Consent Of Registered Agent
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1
2COMMONWEALTH OF KENTUCKY
TREY GRAYSON
SECRETARY OF STATE
STATEMENT OF CONSENT OF REGISTERED AGENT
Pursuant to the provisions of KRS Chapter 271B, 273, 275 or 362, the undersigned hereby consents to act as registered
agent on behalf of the business entity named below and for that purpose submits the following statements:
1. The business entity is
a corporation (KRS 271B or KRS 273)
a limited liability company (KRS 275)
a limited partnership (KRS 362)
2. The name of the business entity is
_______________________________________________________________________________________________.
3. The state or country of incorporation, organization or formation is ___________________________________________.
4. The name of the initial registered agent is
_______________________________________________________________________________________________.
5. The street address of the registered office address in Kentucky is
_______________________________________________________________________________________________.
Street
City
State
Zip Code
_____________________________________________
Signature of registered agent
_____________________________________________
Type or Print Name & Title, if applicable
Date: ______________________________, 20_______
SSC-109 (7/98)
(See attached sheet for instructions)
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