STATEMENT OF 
   PAUL D. PATE 
RESIGNATION OF 
Secretary of State 
 
REGISTERED AGENT 
 State of Iowa 
 
  Read the instructions on the reverse before completing.
 
All items must be completed before the statement of resignation will be considered.
 
Statement 
 
  Name of Business Entity: _____________________________________________________________________
 
 Principal Office Address: ______________________________________________________________________
 
Registered Office Address: ____________________________________________________________________
  
        TO THE ABOVE NAMED BUSINESS ENTITY. Please be advised that notice is hereby given to said business entity that
 ______________________________________, registered agent appearing on the records of the secretary of state for the

      business entity, does hereby resign as the registered agent effective at 12:01 AM on the thirty-first (31st) day after the filing

date of this Statement or the designation of a new registered agent for the business entity, whichever is earlier. The
registered office of the business entity       is       is not discontinued at the same time.
 
    Signature of Registered Agent, or if Agent is an entity, signature of an individual representing the Agent entity:

___________________________________________________
 
Date: ___________________________
  
Certificate of Mailing 
 
  I, _________________________________, registered agent for ________________________________________________,

            appearing on the records of the secretary of state, hereby certify that on    _______________________ I did send a copy of this

        Statement of Resignation of Registered Agent by certified mail to the business entity   at the above principal place of business

      and         to the above registered office, if the office was not discontinued.

   Signature of Registered Agent, or if Agent is an entity, signature of an individual representing the Agent entity:

__________________________________________________
 
  Date: ___________________________
  
635_0987 
Rev. 7/22  
 

                                                          INSTRUCTIONS 
                                               Read the instructions before completing. 

All items must be completed before the application will be considered. 

Please print or type the information required unless a signature is specified. 

If you are uncertain about the accuracy of any of the required information contact the Secretary of State’s O ce
at (515) 281-5204 for assistance. 

Each item number below corresponds to the same number as they appear on the Statement or Certificate of Mailing.

                                                             Statement

1. Insert the complete legal name of the business entity. 
2. Insert the address of the business entity’s principal place of business.
3. Insert the address of the registered office. 
4. Insert name of registered agent reflected in the records of the Iowa Secretary of State. 
5.  Place an “X” in the appropriate box to indicate whether the registered office is also being discontinued. 
6. Sign the statement. 
7. Insert the date the statement was signed. 

                                                   Certificate of Mailing
1. Insert name of registered agent reflected in the records of the Iowa Secretary of State. 
2. Insert the complete legal name of the business entity. 
3. Insert the date the statement was mailed to the business entity. 
4. Place an “X” in the box to indicate that the statement was sent to the business entity’s principal office.
5.  Place   an “X” in the box to indicate that the statement was sent to the registered offices if the registered office is not being
    discontinued. 
6. Sign the certification. 
7. Insert the date the certification was signed. 

NOTES: 
1. There is no filing fee. 
2. The information you provide will be open to public inspection under Iowa Code chapter 22.11. 

                                                   SECRETARY OF STATE 
                                                   Business Services Division 
                                                   Lucas Building, 1st Floor 
                                                   Des Moines, IA 50319 

                                                   Phone: (515) 281-5204 
                                                              FAX: (515) 242-5953 

                                                       Website: sos.iowa.gov