Fillable FORM BCA 5.10/5.20 (rev. Dec. 2003): TATEMENT OF (Illinois Secretary of State)

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FORM BCA 5.10/5.20 (rev. Dec. 2003): TATEMENT OF (Illinois Secretary of State)

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FORM BCA 5.10/5.20 (rev. Dec. 2003)
S
TATEMENT OF CHANGE OF
REGISTERED AGENT AND/OR
REGISTERED OFFICE
Business Corporation Act
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
2
17-782-7808
www.cyberdriveillinois.com
Remit payment in the form of a
check or money order payable
to Secretary of State.
_____________________________________ File #_____________________________ Filing Fee: $25 Approved: ___________
––––––– Submit in duplicate ––––––– Type or Print clearly in black ink ––––––– Do not write above this line –––––––
1. Corporate Name: _______________________________________________________________________________
2. State or Country of Incorporation:___________________________________________________________________
3. Name and Address of Registered Agent and Registered Office as they appear on the records of the Office of the Secretary
of State (before change):
Registered Agent: _______________________________________________________________________________
First Name Middle Name Last Name
Registered Office: _______________________________________________________________________________
Number Street Suite # (P.O. Box alone is unacceptable)
Registered Office _______________________________________________________________________________
City ZIP Code County
4. Name and Address of Registered Agent and Registered Office shall be (after all changes herein reported):
Registered Agent: _______________________________________________________________________________
First Name Middle Name Last Name
Registered Office: _______________________________________________________________________________
Number Street Suite # (P.O. Box alone is unacceptable)
Registered Office _______________________________________________________________________________
City ZIP Code County
5. The address of the registered office and the address of the business office of the registered agent, as changed, will be
identical.
6. The above change was authorized by: (“X” one box only)
a. q Resolution duly adopted by the board of directors. (See Note 4 on reverse.)
b. q Action of the registered agent. (See Note 5 on reverse.)
SEE REVERSE FOR SIGNATURE(S).
Printed by authority of the State of Illinois. January 2015 — 1 — C 135.24
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7. If authorized by the board of directors, sign here. (See Note 4 below.)
The undersigned corporation has caused this statement to be signed by a duly authorized officer who affirms, under
penalties of perjury, that the facts stated herein are true and correct.
Dated _______________________________ , _____ ________________________________________________
Month Day Year Exact Name of Corporation
______________________________________
Any Authorized Officer’s Signature
______________________________________
Name and Title (type or print)
If change of registered office by registered agent, sign here. (See Note 5 below.)
The undersigned, under penalties of perjury, affirms that the facts stated herein are true and correct.
Dated _______________________________ , _____ ________________________________________________
Month Day Year Signature of Registered Agent of Record
________________________________________________
Name (type or print)
If Registered Agent is a corporation,
Name and Title of officer who is signing on its behalf.
NOTES
1. The registered office may, but need not be, the same as the principal office of the corporation. However, the registered
office and the office address of the registered agent must be the same.
2. The registered office must include a street or road address (P.O. Box alone is unacceptable).
3. A corporation cannot act as its own registered agent.
4. Any change of registered agent must be by resolution adopted by the board of directors. This statement must be signed
by a duly authorized officer.
5. The registered agent may report a change of the registered office of the corporation for which he/she is a registered
agent. When the agent reports such a change, this statement must be signed by the registered agent. If a corporation is
acting as the registered agent, a duly authorized officer of such corporation must sign this statement.
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FORM BCA 5.105.20 (rev. Dec. 2003): TATEMENT OF (Illinois Secretary of State)

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Completed 28 August 2020

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