State of North Carolina
Department of the Secretary of State
STATEMENT OF CHANGE OF MAILING ADDRESS
OF SURVIVING ENTITY OF MERGER*
Pursuant to N.C.G.S. §§ 55-15-21(a)(4), 55A-11-09(d)(3) 55A-15-21(a)(4), 57D-7-21(a)(7) and 59-
909(a)(4), as applicable, the undersigned business entity is giving notice that its mailing address has
1. Name of the Business Entity: _____________________________________________________
2. Old Address:
Number and Street (PO Box): ______________________________________________________
City: ____________________ State:
3. New Address:
Number and Street or (PO Box): ____________________________________________________
City: ____________________ State: _______ Zip Code:
4. This Statement will be effective upon filing, unless a future date and time is specified:
This the ____ day of _____________, 20___.
Name of Entity
Type or Print Name and Title
Filing fee is $10. This document must be filed with the Secretary of State.
This form should only be used by the surviving entity in a merger to notify the Secretary of State of a change in its mailing address after Articles of Merger or an
Application for Certificate of Withdrawal by Reason of Merger, Consolidation or Conversion have been filed. This form should not be used to change the registered
office address. A Statement of Change of Registered Office and/or Registered Agent should be used for that purpose.
P. O. BOX 29622
RALEIGH, NC 27626-0622
(Revised January, 2014)