Statement Of Change By Registered Agent - Wyoming Secretary Of State
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1Wyoming Secretary of State
State Capitol Building, Room 110
th
200 West 24
Street
For Office Use Only
Cheyenne, WY 82002-0020
Ph. 307.777.7311
Fax 307.777.5339
Email:
Business@wyo.gov
Statement of Change by Registered Agent
1. This change affects every entity that I represent. (If not, please contact our office.)
2. Name of current registered agent and physical address of current registered office:
Current Registered Agent:
Current Registered Office:
3. New name of registered agent (if applicable) and physical address of new registered office (if applicable):
New Name of Registered Agent:
For consistency the Secretary of State’s Office will only keep one version of the agent’s name on file.
New Registered Office:
4. I hereby certify that I am in compliance with all requirements of W.S. 17-28-101 through W.S. 17-28-111.
5. After the changes are made, the physical address of my registered office and business office will be identical.
6. I hereby certify that every entity I represent has been notified of my name/office change.
Signature: _______________________________________________
Date:
(shall be executed by the registered agent)
(mm/dd/yyyy)
Print Name:
Contact Person:
Title:
Daytime Phone:
Email:
Checklist
If you are a Commercial Registered Agent, changes noted on this form shall also be reflected on your
Commercial Registered Agent form.
Filing Fee: Nonprofit Corporation - $3.00 (by statute); All other business entities - No Fee
Please submit one originally signed document and one exact photocopy of the filing.
Please review form prior to submitting to the Secretary of State to ensure all areas have been
completed to avoid a delay in the processing of your documents.
RA-RO ChangeByRA –11/2012
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