Statement Of Resignation Of Registered Agent

D F The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth PC One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Statement of Resignation FORM MUST BE TYPED of Registered Agent (General Laws Chapter 156D, Section 5.03 and Section 15.09; 950 CMR 113.23) Name of registered agent: ________________________________________________________________________________ Exact name of corporation: ______________________________________________________________________________ Current registered o ce address: __________________________________________________________________________ (number, street, city or town, state, zip code) h e above named registered agent hereby resigns his appointment as registered agent of the corporation. h e registered o ce address will: (Check appropriate box) also be discontinued. remain the same. It is hereby certi? ed that a copy of this statement of resignation shall be furnished to the corporation pursuant to G. L. Chapter 156D, Section 5.03 and Section 15.09. h e appointment is terminated, and the registered o ce discontinued, if so provided, on the thirty-? rst day after the date on which the statement is ? led, unless a later e ective date not more than 90 days from the date and time of ? ling is speci? ed: ____________________________________________________________________________________________ Signed by: ___________________________________________________________________________________________, (signature of registered agent) on this ___________________________________day of ______________________________of ____________________. American LegalNet, Inc. www.USCourtForms.comc156ds503s150995011323 01/13/05<<<<<<<<<********>>>>>>>>>>>>> 2 COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 Statement of Resignation of Registered Agent (General Laws Chapter 156D, Section 5.03 and Section 15.09; 950 CMR 113.23) I hereby certify that upon examination of this statement of resignation, duly submitted to me, it appears that the provisions of the General Laws relative to the organization of corporations have been complied with, and I hereby approve said statement; and the filing fee in the amount of $_____hav- ing been paid, said statement is deemed to have been filed with me this _____________day of _____________, 20______ , at _______a.m./p.m. time E ective date: _________________________________________________ (must be within 90 days of date submitted) WILLIAM FRANCIS GALVIN Secretary of the Commonwealth Filing fee: $25 for paper or fax ? lings. No fee if ? led electronically. TO BE FILLED IN BY CORPORATION Contact Information: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Telephone: ___________________________________________________ Email: ______________________________________________________ Upon ? ling, a copy of this ? ling will be available at www.sec.state.ma.us/cor. If the document is rejected, a copy of the rejection sheet and rejected document will be available in the rejected queue. American LegalNet, Inc. www.USCourtForms.com