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Form Na-03 - Cancellation Of Statement Of Appointment Of Agent For A Nonprofit Association

STATE OF NORTH CAROLINA

Department of the Secretary of State

CANCELLATION OF STATEMENT OF APPOINTMENT OF AGENT FOR A NONPROFIT ASSOCIATION

Pursuant to §59B-11 of the General Statutes of North Carolina, the undersigned Nonprofit Association submits the following for the

purpose of canceling its statement of appointment of an agent.

1. The name of the Nonprofit Association is: _____________________________________________________________

2. The street address and county of the Nonprofit Association is:

Number and Street: _______________________________________________________________________

City, State, Zip Code: ________________________________________

County: _________________

3. The mailing address if different from the street address of the Nonprofit Association:

__________________________________________________________________________________________

The statement of appointment of agent filed on _______________________ is hereby cancelled.

5. This statement will be effective upon filing, unless a date and/or time is specified: _____________________

This is the _____day of _______________, 20____.

__________________________________________

(Name of Entity)

__________________________________________

(Signature)

__________________________________________

(Type or Print Name and Title)

Notes: 1. Filing fee is $5.00. One executed statement must be filed with the Secretary of State. *The Secretary of State is not an

agent for service of any process, notice, or demand on any nonprofit association.

(January 2007)

(Form NA-03)

CORPORATIONS DIVISION

P.O. BOX 29622

RALEIGH, NC 27626-0622

Form Na-03 - Cancellation Of Statement Of Appointment Of Agent For A Nonprofit Association