Notice Of Change Of Officials (Domestic Cooperative) {08-468}

08-468 Rev D-Coop Change of Officials 1 of 2 Domestic Cooperative (AS 10.15) This Notice of Change of Officials form is only for Domestic Cooperatives and is used to report changes inofficers, directors, and shareholder information between biennial reporting periods. This Notice of Change of Officials will not be filed if the entity222s biennial report is not current. To verify theentity222s biennial report due date, go online to www.Corporations.Alaska.Gov and select SearchCorporations Database Standard processing time for complete and correct filings submitted to this office is approximately 10-15business days. All filings are reviewed in the date order they are received. The information you submit is a public record and will be posted on the State222s website. COR Corporations Section State Office Building, 333 Willoughby Avenue, 9th Floor PO Box 110806, Juneau, AK 99811-0806 Phone: (907) 465-2550 225 Fax: (907) 465-2974 Email: corporations@alaska.gov Website: Corporations.Alaska.Gov Notice of Change of Officials 1. Important: AS 10.15.331 Each Domestic Cooperative is required to notify this office when there is a change of officials. 227 AS 10.15.331 Failure to meet this requirement may result in involuntary dissolution of the entity222s authority to transact business in the State of Alaska. 227 AS 10.15.505 and AS 10.06.633(5)(7) The Domestic Cooperative is to keep and make available the records of the official(s) changes. 227 AS 10.15.315 2. Fee: $25 Nonrefundable Filing Fee (CORF) 3 AAC 16.040(c) Mail this form and the non-refundable $25 filing fee in U.S. dollars to the letterhead address. Make the check or money order payable to the State of Alaska, or use the attached credit card payment form. 3. Entity Information: AS 10.15.331 Entity Name: Alaska Entity Number: FOR DIVISION USE ONLY T HE S TATE ALASKA of Department of Commerce, Community and Economic Development Division of Corporations, Business and Professional Licensing American LegalNet, Inc. www.FormsWorkFlow.com 08-468 Rev D-Coop Change of Officials 2 of 2 4. REMOVE from Record: AS 10.15.331(b) The following officials (officers, directors, shareholders, and general manager) will be completely removed from the record as a result of this filing: Name: Name: Name: Name: If an official is not being removed from record, then list them in Item #5 below (with their current information). 5. ALL Current Officials: AS 10.15.331(b) and The following is a complete list of ALL remaining and new officials who will be on record as a result of this filing. Domestic Cooperatives must have a President, Vice-President, Secretary, Treasurer, and at least three (3) Directors. Each principal officer must be a Director of the Cooperative, except for Secretary, Treasurer and one Vice-President (if the by-laws provide for more than one). 227 AS 10.15.175 and 10.15.140(b) List ALL officials and their current information to be on record. BOLD fields are required. % Owned Shareholder PRESIDENT VICE - PRESIDENT SECRETARY TREASURER DIRECTOR (3) General Manager Assistant Secretary Assistant Treasurer FULL LEGAL NAME COMPLETE MAILING ADDRESS If necessary, use the following supplement page and include all information required above in Item #5. 6. Required Signature: AS 10.15.331(b) and AS 10.06.825 The Notice of Change of Officials must be signed by a principal officer (i.e., the president or vice-president) of the cooperative. Persons who sign documents filed with the commissioner that are known to the person to be false in material respects are guilty of a class A misdemeanor. Signature: Date: Printed Name: Title of Authorized Signer: (Must be signed by a principal officer. A director is not an authorized signer.) American LegalNet, Inc. www.FormsWorkFlow.com 08-468a Rev D-Coop Change of Officials (SUPPLEMENT) If used, this supplement must be returned with Form 08-468 Notice of Change of Officials SUPPLEMENT Entity Name: Alaska Entity Number: 4. REMOVE from Record (continued from Page 2): AS 10.15.331(b) The following officials (officers, directors, shareholders, and general manager) will be completely removed from the record as a result of this filing: Name: Name: Name: Name: If an official is not being removed from record, then list them in Item #5 below (with their current information). 5. ALL Current Officials (continued from Page 2): AS 10.15.331(b) and The following is a complete list of ALL remaining and new officials who will be on record as a result of this filing. Domestic Cooperatives must have a President, Vice-President, Secretary, Treasurer, and at least three (3) Directors. Each principal officer must be a Director of the Cooperative, except for Secretary, Treasurer and one Vice-President (if the by-laws provide for more than one). 227 AS 10.15.175 and 10.15.140(b) List ALL officials and their current information to be on record. BOLD fields are required. % Owned Shareholder PRESIDENT VICE - PRESIDENT SECRETARY TREASURER DIRECTOR (3) General Manager Assistant Secretary Assistant Treasurer FULL LEGAL NAME COMPLETE MAILING ADDRESS If necessary to complete Items #4 and #5, make copies of this SUPPLEMENT page. American LegalNet, Inc. www.FormsWorkFlow.com 08-561 Rev 7/14/16 Contact Information Return this form with your filing This information may be used by the Division to assist with processing your attached filings This form will not be filed for record, or appear online COR Corporations Section State Office Building, 333 Willoughby Avenue, 9th Floor PO Box 110806, Juneau, AK 99811-0806 Phone: (907) 465-2550 Fax: (907) 465-2974 Email: corporations@alaska.gov Website: Corporations.Alaska.Gov Contact Information Entity Information Enter your entity information as it appears on this filing. Entity Name: AK Entity #: Contact Person Whom may we contact with any questions or problems with this filing? Company: Contact: Mailing Address: Address: City: State: ZIP: Phone: Email: Document Return Address Provide an address for the return of your filed documents. Return my filings to the address provided ABOVE Return my filings to this address provided BELOW Company: Contact: Mailing Address: Address: City: State: ZIP: FOR DIVISION USE ONLY T HE S TATE ALASKA of Department of Commerce, Community and Economic Development Division of Corporations, Business and Professional Licensing American LegalNet, Inc. www.FormsWorkFlow.com All major credit cards are accepted. For security purposes, do not email credit card information. Include this credit card payment form with your application. Name of Applicant or Licensee: Program Type: License Number (if applicable): I wish to make payment by credit card for the following (check all that apply): AMOUNT Application Fee: License or Renewal Fee: Other (name change, wall certificate, fine, duplicate license, exam, etc.): 1. 2. TOTAL: Name (as shown on credit card): Mailing Address: Phone Number: Email (optional): Signature of Credit Card Holder: 08-4438 Rev 12/26/18 Credit Card Payment Form (all major cards accepted) State of Alaska Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing PO Box 110806, Juneau, AK 99811 Phone: (907) 465-2550 Credit Card Payment Form CREDIT CARD INFO: Your payment cannot be processed unless all fields are completed! All four fields MUST be completed! This section will be destroyed after the payment is processed. 1. Account Number : 2. Expiration Date: 3. Billing ZIP Code: 4 . Security Code : FOR DIVISION USE ONLY T HE S TATE ALASKA of Department of Commerce, Community , and Economic Development Division of Corporations, Business and Professional Licensing American LegalNet, Inc. www.FormsWorkFlow.com