Form Ssc-109 - Statement Of Consent Of Registered Agent

Form Ssc-109 - Statement Of Consent Of Registered Agent - 1998

COMMONWEALTH OF KENTUCKY

JOHN Y. BROWN III

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)

Form Ssc-109 - Statement Of Consent Of Registered Agent - 1998