Form Statement Of Change For Registered Agent/office Page 3
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3INSTRUCTIONS – STATEMENT OF CHANGE
Please complete all sections of the Statement of Change form. USE DARK INK ONLY. For an electronic,
fillable version of this form, please visit our website at
UBI Number: If available, please enter your existing Unified Business Identifier (UBI Number) as currently
recorded with the Office of the Secretary of State, in the box in the upper right hand corner of page 1.
Section 1
Indicate the entity name as it is currently recorded with the Office of the Secretary of State.
Section 2
Indicate the entity type for the Statement of Change. (select only one option)
Section 3
Provide the current registered agent as recorded with the Office of the Secretary of State.
Section 4
Provide the NEW registered agent in Washington State. The registered agent may be an individual who is a
resident of Washington State, or a business entity registered with the Secretary of State’s office. The agent
must have a physical address in Washington State where they can be located. An alternative mailing address
may be used in addition to the physical address. The mailing address must also be in Washington State. The
registered agent must print their name and sign the consent to serve as registered agent
Section 5
Select the authorized title of the person submitting the Statement of Change. The person signing will provide
their signature, printed name and title, the date signed, and phone number. If you are unsure that you have
authority to sign this Statement of Change then please review state requirements for the type of entity
requested or consult our office at 360-725-0377 for requirements.
Additional Information:
FEES: There is no filing fee for standard service. If expedited service is requested, include an additional
$50.00 and write “EXPEDITE” on the outside of the envelope. Make the checks or money orders payable to
“Secretary of State”. (All filing fees are non-refundable)
Mail completed forms and payment to:
Secretary of State
Corporation Division
801 Capitol Way S
PO Box 40234
Olympia WA 98504-0234
If you have questions, need assistance or would like to provide feedback please visit the Corporations Division
website at
or call 360-725-0377.
Statement of Change
Washington Secretary of State
Revised 07/10
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