Form 635_0114 - Application For Amended Certificate Of Authority - 2011 Page 2
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2name _________________________________________________________________________________
address _______________________________________________________________________________
city, state, zip __________________________________________________________________________
name _________________________________________________________________________________
address _______________________________________________________________________________
city, state, zip __________________________________________________________________________
name _________________________________________________________________________________
address _______________________________________________________________________________
city, state, zip __________________________________________________________________________
Please attach additional pages if needed.
8. A certificate of existence, or a document of similar import, duly authenticated by the official having custody
of corporate records in the state or country of incorporation, accompanies this application.
9. Signature ______________________________________________________________________________
Type or print name and title _______________________________________________________________
NOTES:
1. The filing fee is $100.00. Make checks payable to SECRETARY OF STATE.
2. The document is to be signed by the chairperson of the board, the president, or other officer of the corpora-
tion. If directors have not been selected, the document is to be signed by an incorporator. If the corporation
is in the hands of a court appointed fiduciary, the document is to be signed by the fiduciary. A copy of a
signature is acceptable for filing. Verification is not required.
3. One copy of the document is to be delivered to the Secretary of State for filing.
4. The effective time and date of the document is the later of the following:
a. the time of filing on the date it is filed;
b. the time specified in the document on the date it is filed;
c. the time and date specified in the document, not later than 90 days after the date it is filed.
5. The information you provide will be open to public inspection under Iowa Code chapter 22.11.
SECRETARY OF STATE
Business Services Division
Lucas Building, 1st Floor
Des Moines, Iowa 50319
Phone: (515) 281-5204
FAX: (515) 281-7142 or (515) 242-5953
Website:
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