FORM NFP 105.10/105.20 (rev. Dec. 2003)
STATEMENT OF CHANGE
OF REGISTERED AGENT AND/OR
REGISTERED OFFICE
General Not For Profit Corporation Act
Secretary of State
D
epartment of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-7808
www.cyberdriveillinois.com
Remit payment in the form of a
check or money order payable
to Secretary of State.
____________________________________ File #______________________________ Filing Fee: $5 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 321.8