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Officers Statement - Nevada

Officers Statement Form. This is a Nevada form and can be used in Corporation Secretary Of State .
 Fillable pdf Last Modified 1/12/2010
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DEAN HELLER Secretary of State 204 North Carson Street, Suite 1 Carson City, Nevada 89701-4299 (775) 684 5708 Website: secretaryofstate.biz Officers Statement* (PURSUANT TO NRS 80.030) Important: Read attached instructions before completing form. ABOVE SPACE IS FOR OFFICE USE ONLY Officers Statement (Pursuant to NRS 80.030) 1. Name of corporation (provide modified name also if filed pursuant to 80.025): ________________________________________________________________________ ______ (currently on file in Nevada) ________________________________________________________________________ ______ 2. State of incorporation:__________________________________________________________ 3. Changes reflected by filing of document: (check the appropriate spaces and/or describe under "other") ______ Name ______ Stock ______ Purpose ______ Dissolution ______ Merger (if survivor is qualified in Nevada) ______ Other (specify changes): 4. Signature (must be signed by an officer of the corporation): ________________________________________ __________________________ Signature of Officer Making Statement Title of Officer * Submit this form with either a certified copy of or a certificate evidencing the filing of any document amendatory or otherwise relating to the original articles in the place of the corporations creation. IMPORTANT: Failure to include any of the above information and submit with the proper fees may cause this filing to be rejected. SUBMIT IN DUPLICATE This form must be accompanied by appropriate fees. See attached fee sch edule. Nevada Secretary of State AM 80.030 O.S. 2003 Revised on: 11/25/03
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