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NFP 105.10/105.20
FORM
(rev. Dec. 2003)
statement of change
of registered agent and/or
registered office
General Not For Profit Corporation Act
Jesse White, Secretary of State
Department of Business Services
501 S. Second St., Rm. 328
Springfield, IL 62756
217-782-7808
Remit payment in the form of a
check or money order payable
to Secretary of State.
____________________________________ File #______________________________
Filing Fee: $5
Approved: ___________
———— submit in duplicate ———— type or Print clearly in black ink ———— do not write above this line ————
1. Corporate Name: _______________________________________________________________________________
2. State or Country of Incorporation: __________________________________________________________________
3. Name and Address of Registered Agent and Registered Office as they appear on the records of the Office of the
Secretary of State (before change):
Registered Agent: _______________________________________________________________________________
First Name
Middle Name
Last Name
Registered Office: _______________________________________________________________________________
Number
Street
Suite # (P.O. Box alone is unacceptable)
Registered Office
_______________________________________________________________________________
City
ZIP Code
County
4. Name and Address of Registered Agent and Registered Office shall be (after all changes herein reported):
Registered Agent: _______________________________________________________________________________
First Name
Middle Name
Last Name
Registered Office: _______________________________________________________________________________
Number
Street
Suite # (P.O. Box alone is unacceptable)
Registered Office
_______________________________________________________________________________
City
ZIP Code
County
5. The address of the registered office and the address of the business office of the registered agent, as changed, will be
identical.
6. The above change was authorized by: (“X” one box only)
a.
Resolution duly adopted by the board of directors. (see note 4 on reverse.)
b.
Action of the registered agent. (see note 5 on reverse.)
see reVerse for signatUre(s).
Printed by authority of the State of Illinois. February 2011 — 1 — C 321.7
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