State of Missouri
John R. Ashcroft, Secretary of State
Corporations Division
PO Box 778 / 600 W. Main St., Rm. 322
Jefferson City, MO 65102
Statement of Change of Registered Agent and/or Registered Office
By a Foreign or Domestic For Profit or Nonprofit Corporation or a Limited Liability Company
1. This form is to be used by either a for profit or nonprofit corporation or a limited liability company to change either or both the
name of its registered agent and/or the address of its existing registered agent.
2. There is a $10.00 fee for filing this statement.
3. PO Box may only be used in conjunction with a physical street address.
4. Agent and address must be in the State of Missouri.
5. The corporation may not act as its own agent.
Charter #:
1. The name of the business entity is
2. The address, including street and number, of its present registered office (before change) is
Address City/State/Zip
3. The address, including street and number, of its registered office is hereby changed to:
Address (PO Box may only be used in conjunction with a physical street address) City/State/Zip
4. The name of its present registered agent (before change) is:
5. The name of the new registered agent is:
Authorized signature of new registered agent must appear below:
(May attach separate originally executed written consent to this form in lieu of this signature)
6. The address of its registered office and the address of the business office of its registered agent, as changed, will be identical.
7. The change was duly authorized by the business entity named above.
In Affirmation thereof, the facts stated above are true and correct:
(The undersigned understands that false statements made in this filing are subject to the penalties provided under Section 575.040. RSMo)
Authorized signature of officer, member, manager or, if applicable, chairman of the board Printed Name
Title Date
Name and address to return filed document:
City, State, and Zip Code:
Corp. 59 (01/2017)
This form is designed to be filled out online for your convenience.
Complete the necessary information, print, sign and mail.