Vermont Secretary of State, 128 State Street Montpelier, VT 05633-1104

Name of entity:

 
The street address, of its current registered office:

street:
city: VERMONT         zipcode:

If the current registered office is to be changed, the street address of the new registered office:

street:
city: VERMONT         zipcode: 

The name of its current registered agent:
If the current registered agent is to be changed, the name and business address of the new
registered agent and the new agent's written consent (either on this statement or attached)
to the appointment:

Name of new agent:

street:
city:  VERMONT          zipcode: 

Signature of NEW agent___________________________________________________________

If the registered agent is changing the street address of his or her business office, and the street address of the registered office of the corporation or LLC for which he or she is registered agent, the corporation or LLC must be notified in writing of the change and signing (either manually or in facsimile) and delivering to the Secretary of State for filing a statement that complies with the requirements and recites that the corporation or LLC has been notified of the change.


Signature_______________________________Title: Date:

Fees: $20.00 (profit corporation T11A) $5.00 (nonprofit corporation T11B) To receive a dated copy, please file in duplicate along with a stamped, self-addressed envelope.