Non-Refundable Processing Fee: $15.00 Entity File Number: _________________________
Entity Name: ___________________________________________________________________________________________
For each Yes button that you mark the question will appear below for you to fill out.
1). Do you want to Change the Business Purpose? Yes No
1). If Yes, what is the new Business Purpose? ___________________________________________________________________________
2). Do you want to Change the Registered Agent or the Address of the Registered Agent? Yes No
2). If Yes, who is the new Registered Agent, or the new Address of the Registered Agent?
______________________________________________________________________________________________
The address must be listed if you have a non-commercial registered agent. See instructions for further details.
Address of the Registered Agent: __________________________________________________________________
Utah Street Address Required, PO Boxes can be listed after the Street Address
City _____________________________________________________________________________ State UT Zip __________
3). Do you want to Change the Principal Address of the Business Entity? Yes No
3). If Yes, what is the new Principal Address?
Address: ________________________________________________ City ___________________ State ______ Zip __________
4). Do you want to Add individuals to the Business Entity? Yes No
4). If Yes, who do you want to Add to the Business Entity and what Position will they hold?
Name: ____________________________________________ Position: ___________________________________________
Address: ________________________________________________ City ___________________ State ______ Zip __________
Name: ____________________________________________ Position: ___________________________________________
Address: ________________________________________________ City ___________________ State ______ Zip __________
5). Do you want to Remove individuals from the Business Entity? Yes No
5). If Yes, who do you want to Remove from the Business Entity and what Position do they hold?
Name: _________________________________________ Position: ___________________________________________
Name: _________________________________________ Position: ___________________________________________
Name: _________________________________________ Position: ___________________________________________
6). Do you want to Change the Address of the Business Entity’s Principal(s)? Yes No
6). If Yes, who is the Principal(s) whose Address you wish to Change?
Name: ____________________________________________ Position: ___________________________________________
Address: ________________________________________________ City ___________________ State ______ Zip __________
Name: ____________________________________________ Position: ___________________________________________
Address: ________________________________________________ City ___________________ State ______ Zip __________
Optional Inclusion of Ownership Information: This information is not required.
Is this a female owned business? Yes No
Is this a minority owned business? Yes No If yes, please specify: _____________________________________
Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you may use
the business entity physical address rather than the residential or private address of any individual affiliated with the entity.
Under penalties of perjury and as an authorized authority, I declare that this statement of change(s), has been examined by me and is, to the best of
my knowledge and belief, true, correct and complete.
Name/Title: ___________________________________ Signature: _________________________________ Date: _____________________
State of Utah
Department of Commerce
Division of Corporations & Commercial Code
Benefit Corporation Registration Information Change Form
This form cannot be hand written.
Link to Corporation Registration Information Change Form Addendum
Select/Type the race of the owner here
Sign here after printing form
Mailing/Faxing Information:
www.corporations.utah.gov/contactus.html
www.corporations.utah.gov
