Form Mllc-12a - Limited Liability Company Statement Of Change Of Foreign Qualification - 2013 Page 2
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1
2SIXTH:
Complete only if there is a change to the registered agent information.
The Registered Agent is a: (select either a Commercial or Noncommercial Registered Agent)
Commercial Registered Agent
CRA Public Number: ____________________
__________________________________________________________________________________
(Name of commercial registered agent)
Noncommercial Registered Agent
__________________________________________________________________________________
(Name of noncommercial registered agent)
__________________________________________________________________________________
(physical location, not P.O. Box – street, city, state and zip code)
__________________________________________________________________________________
(mailing address if different from above)
SEVENTH:
Pursuant to 5 MRSA
§§105.2
or 108.3, the registered agent listed above has consented to serve as the registered agent
for this limited liability company.
EIGHTH:
The new state or other jurisdiction under whose law the foreign limited liability company is now formed
(if no change, so
indicate):
_________________________________________________________________________________________
A certificate of existence or such other document that the Secretary of State determines to be suitable for purposes
of proving the valid existence of the foreign limited liability company under the law of the State or other jurisdiction
is attached. The certificate or other document must not have been issued more than 90 days before the delivery of
this statement to the office of the Secretary of State.
NINTH:
Other changes to the statement, if any, are set forth in Exhibit______attached and made a part hereof.
Dated ______________________________
___________________________________________________
(Authorized Signature**)
___________________________________________________
(Type or print name)
*The limited liability company name as used in the State of Maine must contain one of the following: “limited liability company” or
“limited company” or the abbreviation “L.L.C.,” “LLC,” “L.C.” or “LC” or, in the case of a low-profit limited liability company, “L3C”
or “l3c” – see
31 MRSA
1508). If the addition of these words is the only difference from the limited liability company's real name in its
jurisdiction of organization, then no fictitious name filing is required.
**Pursuant to
31 MRSA
§1676.1, this statement MUST be signed by a person authorized by the foreign limited liability company.
The execution of this statement constitutes an oath or affirmation under the penalties of false swearing under
17-A MRSA
§453.
Please remit your payment made payable to the Maine Secretary of State.
Submit completed form to:
Secretary of State
Division of Corporations, UCC and Commissions
101 State House Station
Augusta, ME 04333-0101
Telephone Inquiries: (207) 624-7752
Email Inquiries:
CEC.Corporations@Maine.gov
Form No. MLLC-12A (2 of 2) Rev. 1/30/2013
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