Statutory Trust Certificate Of Trust, Consent To Appointment By Registered Agent Form - Wyoming Secretary Of State Page 3

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6. Future effective date or time of this certificate if it is NOT to be effective upon the filing of this
certificate:
(Date – mm/dd/yyyy)
7. Execution:
Trustee Signature: _________________________________________
Date:
(mm/dd/yyyy)
Print Name:
Trustee Signature: _________________________________________
Date:
(mm/dd/yyyy)
Print Name:
Trustee Signature: _________________________________________
Date:
(mm/dd/yyyy)
Print Name:
Contact Person:
Daytime Phone Number:
Email:
(Email provided will receive annual report reminders and filing evidence)
*May list multiple email addresses
Note:
An annual report will be due on or before January 2 each year. If not paid within thirty (30) days from the due
date the entity will become delinquent, increasing the annual report fee to $200. If not filed by April 1, the entity will
be subject to dissolution/revocation.
ST-CertificateTrust - Revised October 2015

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