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Instructions For Completion Of The Interim Notice Of Change Of Officer/director Form - State Of Connecticut

INSTRUCTIONS

FOR COMPLETION

OF THE INTERIM

NOTICE

OF CHANGE

OF OFFICER/DIRECTOR

FORM

Domestic and Foreign Corporations

Instructions corresnond with numbered entries on the form

NAME OF CORPORATION:

Please provide the complete name of the corporation as it

currently appears on the records of the Secretary of the State. If the notice is being filled

by a foreign corporation, such corporation should provide the name under which it is

currently authorized to transact business in Connecticut.

NEW OFFICER/DIRECTOR

INFORMATION:

Please print or type the full name of the

corporation’s officers and directors, their titles, including a check following the statement

“Check if Director” if applicable, and their residence and business addresses. Complete

street addresses including a street number, street name, city, state, postal code and country

ifother than the United States are required. Note: P.O. boxes are only acceptable as

additional

information.

DIRECTORS/OFFICERS

WHO HAVE CEASED TO HOLD OFFICE: Please print or

type the full name of directors/officers who have ceased holding director or officer

positions within the corporation and their titles, including a check following the statement

“Check if Director” if applicable.

EXECUTION:

The document must be executed by an authorized official of the

corporation.

That person must print or type their name, state the capacity under which

they sign. The execution constitutes a legal statement under the penalties of false

statement that the information provided in the document is true.

Instructions For Completion Of The Interim Notice Of Change Of Officer/director Form - State Of Connecticut