Cancellation Of Statement Of Appointment Of Agent {NA-03}

BUSINESS REGISTRATION DIVISION P.O. BOX 29622 RALEIGH, NC 27626-0622 (Revised August 2017) (Form NA-03) STATE OF NORTH CAROLINA Department of the Secretary of State CANCELLATION OF STATEMENT OF APPOINTMENT OF AGENT FOR A NONPROFIT ASSOCIATION Pursuant to 24759B-11 of the General Statutes of North Carolina, the undersigned Nonprofit Association submits the following for the purpose of canceling its statement of appointment of an agent. 1. The name of the Nonprofit Association is: 2. The street address and county of the Nonprofit Association is: Number and Street: City, State, Zip Code: County: 3. The mailing address if different from the street address of the Nonprofit Association: 4. The statement of appointment of agent filed on is hereby cancelled. 5. This statement will be effective upon filing, unless a date and/or time is specified: 6. This is the day of , 20. Name of Business Signature Type or Print Name and Title Notes: Filing fee is $5.00. This statement must be filed with the Secretary of State. *The Secretary of State is not an agent for service of any process, notice, or demand on any nonprofit association. American LegalNet, Inc. www.FormsWorkFlow.com