Statement Of Resignation Of Agent {NA-04}

BUSINESS REGISTRATION DIVISION P.O. BOX 29622 RALEIGH, NC 27626-0622 (Revised August 2017) Form NA-04 State of North Carolina Department of the Secretary of State STATEMENT OF RESIGNATION OF AGENT Pursuant to 24759B-11 of the General Statutes of North Carolina, the undersigned hereby submits the following statement: 1. I, , (type or print name), hereby resign my appointment as agent for the following entity: . 2. The undersigned certifies that written notice of this resignation as agent of the entity has been mailed or delivered to the entity as follows: Name and Title of Individual Address City, State, Zip Code 3. The Agent222s registered office address is to be discontinued. (check here if applicable) This the day of , 20 Name of Entity Signature Type or Print Name and Title NOTES No filing fee. This document 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