CERTIFICATE OF CHANGE 

                                                 OF 
 
                                     (Insert Name of Domestic Corporation) 
 
                          Under Section 803-A of the Not-for-Profit Corporation Law 
 
 FIRST: The name of the corporation is: 
 
 If the name of the corporation has been changed, the name under which it was formed is: 
 
 SECOND: The certificate of incorporation was filed by the Department of State on: 
 
 THIRD: The change(s) effected hereby are: (Check appropriate statement(s)) 
 The county location, within this state, in which the office of the corporation is located, is 
 changed to: 
 The address to which the Secretary of State shall forward copies of process accepted on 
 behalf of the corporation is changed to read in its entirety as follows: 
 
                                                                                                                                               . 

 The corporation hereby:             (Check One) 
 
                          Designates 
 
                          as its registered agent upon whom process against the corporation may be served. 

                          The street address of the registered agent is: 

                                                                                                                                                              . 
 
                          Changes the designation of its registered agent to:  

                          The street address of the registered agent is: 

                                                                                                                                                              . 
 
                          Changes the address of its registered agent to: 
 
                                                                                                                                                              . 

                          Revokes the authority of its registered agent. 
 DOS-1562-f  (Rev. 02/16)                                                                                                                                       Page 1 of 2 

 FOURTH: The change was authorized by the board of directors. 
 
             X 
                          (Signature)                                            (Name of Signer) 
 
                                                                                 (Title of Signer) 
 
                                      CERTIFICATE OF CHANGE 
                                      OF 
 
                                      (Insert Name of Domestic Corporation) 
 
                           Under Section 803-A of the Not-for-Profit Corporation Law 
 
 Filer’s Name:   

 Address: 

 City, State and Zip Code: 
 
 NOTES:  
 1. The name of the corporation and its date of incorporation provided on this certificate must exactly match the 
      records of the Department of State.  This information should be verified on the Department of State’s website 
      at www.dos.ny.gov. 
 2. This form was prepared by the New York State Department of State. You are not required to use this form. You  
     may draft your own form or use forms available at legal stationery stores.  
 2. The Department of State recommends that all documents be prepared under the guidance of an attorney.  
 3. The certificate must be submitted with a $20 filing fee. 
 
 For Office Use Only 

 DOS-1562-f  (Rev. 02/16)                                                                                           Page 2 of 2