Form Na-04 - Statement Of Resignation Of Agent printable pdf download

Form Na-04 - Statement Of Resignation Of Agent

State of North Carolina

Department of the Secretary of State

STATEMENT OF RESIGNATION OF AGENT

Pursuant to §59B-11 of the General Statutes of North Carolina, the undersigned hereby submits the following statement:

1. I, ___________________________________________________, (type or print name), hereby resign my appointment as

agent for the following entity: _________________________________________________________________.

2. The undersigned certifies that written notice of this resignation as agent of the entity has been mailed or delivered to the entity as

follows:

Name and Title of Individual________________________________________________________________________

Address_________________________________________________________________________________________

City, State, Zip Code_______________________________________________________________________________

3. The Agent’s registered office address is to be discontinued. (check here____ if applicable)

This the ______ day of ___________________ , 20 _____

___________________________________

Name of Entity

___________________________________

Signature

___________________________________

Type or Print Name and Title

NOTES

No filing fee. This document 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.

CORPORATIONS DIVISION

P.O. BOX 29622

RALEIGH, NC 27626-0622

January 2007

(Form NA-04)

Form Na-04 - Statement Of Resignation Of Agent