Agent's Statement Of Change Of Registered Office Address (North Carolina)
This form is an agent's statement of change of registered office address in North Carolina. The form provided here is simply a sample of what the actual Form BN-12 looks like.
State of North Carolina
Department of the Secretary of State
AGENT'S STATEMENT OF CHANGE OF REGISTERED OFFICE ADDRESS
Pursuant to §55-5-02, §55A-5-02, §55-15-08, and §55A-15-08 of the General Statutes of North Carolina, the undersigned submits the following for the purpose of changing the address of the registered office in the State of North Carolina of the corporation named below:
1. The name of the corporation is: ___________________________
2. The street address and county of the current registered office of the corporation is:
Number and Street: _____________________________________
City _____________________________________
State _____________________________________
Zip Code: _____________________________________
County: _____________________________________
3. The mailing address if different from the street address of the current registered office is:
_____________________________________
4. The street address and county of the new registered office of the corporation is:
Number and Street: _____________________________________
City _____________________________________
State _____________________________________
Zip Code: _____________________________________
County: _____________________________________
5. The mailing address if different from the street address of the new registered office is:
6. The name of the current registered agent is: ________________________________________________
7. The address of the corporation's registered office and the address of the business office of its registered agent, as changed, will be identical.
8. The undersigned certifies that the corporation has been notified in writing of the change of address of the business office of the registered agent.
9. This statement will be effective upon filing, unless a date and/or time is specified:
____________________________________
This is the _________ day of _____________________, 20_____.
________________________________________________
________________________________________________(Signature)
_______________________________________________ (Type or Print Name and Title)
Note: Filing Fee is $5.00. One executed and one exact or conformed copy of this statement must be filed with the Secretary of State.
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INSTRUCTIONS FOR FILLING OUT THIS FORM
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Item 1 Enter the complete name of the corporation exactly as it appears in the records of the Secretary of State.
Item 2 Enter the complete street address and county of the current registered office exactly as it appears in the records of the Secretary of State.
Item 3 Enter the complete mailing address of the registered office only is it is different from the street address shown in Item 2.
Item 4 Enter the complete street address and county of the new registered office.
Item 5 Enter the complete mailing address of the new registered office only if it is different from the street address shown in Item 4.
Item 6 Enter the name of the registered agent exactly as it appears in the records of the Secretary of State.
Item 7 See form.
Item 8 See form.
Item 9 The document will be effective on the date and at the time of filing, unless a delayed date or an effective time (on the day of filing) is specified. If a delayed effective date is specified without a time, the document will be effective at 11:59:59 p.m. on the day specified. If a delayed effective date is specified with a time, the document will be effective on the day and at the time specified. A delayed effective date may be specified up to and including the 90th day after the day of filing.
Date and Execution
Enter the date the document was executed.
In the blanks provided enter:
· The name of the corporate registered agent which is executing the statement; if the registered agent is an individual, leave blank.
· The signature of the registered agent or of the representative of the corporation which is acting as the registered agent.
· The name of the registered agent or the name and the title of the above-signed representative.