Interim Notice Form – Fill Out and Use This PDF

SECRETARY OF THE STATE OF CONNECTICUT

MAILING ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, P.O. BOX 150470, HARTFORD, CT 06115-0470

DELIVERY ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, 30 TRINITY STREET, HARTFORD, CT 06106

PHONE: 860-509-6003

WEBSITE: www.concord-sots.ct.gov

INTERIM NOTICE OF CHANGE OF

MANAGER/MEMBER

LIMITED LIABILITY COMPANY-DOMESTIC & FOREIGN

C.G.S. §34-247k(f)

USE INK. COMPLETE ALL SECTIONS. PRINT OR TYPE. ATTACH 81/2 X 11 SHEETS IF NECESSARY.

1.COMPLETE NAME OF LIMITED LIABILITY COMPANY:(REQUIRED):(MUST MATCH OUR RECORDS EXACTLY AND INCLUDE BUSINESS DESIGNATION I.E. LLC, L.L.C., ETC.)

2.*NEW MANAGER/MEMBER INFORMATION: (NEW INFORMATION MUST INCLUDE NAME, TITLE, RESIDENCE AND BUSINESS ADDRESS)

(NOTE: ADDING A NEW MANAGER/MEMBER DOES NOT REPLACE AN EXISTING MANAGER/MEMBER. PROCEED TO SECTION 3 TO REMOVE EXISTING MANAGER/MEMBER, IF APPLICABLE).

NAME:		TITLE:
RESIDENCE ADDRESS: (P.O.BOX UNACCEPTABLE)		BUSINESS ADDRESS: (P.O.BOX UNACCEPTABLE)
STREET:		STREET:
CITY:		CITY:
STATE:	ZIP:	STATE:	ZIP:
NAME:		TITLE:
RESIDENCE ADDRESS: (P.O.BOX UNACCEPTABLE)		BUSINESS ADDRESS: (P.O.BOX UNACCEPTABLE)
STREET:		STREET:
CITY:		CITY:
STATE:	ZIP:	STATE:	ZIP:
NAME:		TITLE:
RESIDENCE ADDRESS: (P.O.BOX UNACCEPTABLE)		BUSINESS ADDRESS: (P.O.BOX UNACCEPTABLE)
STREET:		STREET:
CITY:		CITY:
STATE:	ZIP:	STATE:	ZIP:
PAGE 1 OF 2			Rev. 7/2017

3. MANAGER(S)/MEMBER(S) WHO HAVE CEASED TO BE MANAGER(S)/MEMBER(S):

NOTE: NAME AND TITLE MUST MATCH OUR RECORDS EXACTLY OTHERWISE CHANGES WILL NOT BE REFLECTED. BE CAREFUL TO INCLUDE ITEMS SUCH AS JR., SR., MIDDLE INITIALS, ETC. CHECK CONCORD ONLINE FOR NAME OF RECORD. INDIVIDUAL/ENTITY WILL

ONLY BE REMOVED FROM THOSE TITLES INDICATED, THEREFORE, BE SURE TO INCLUDE ALL APPLICABLE TITLES.

NAME:	TITLE:
NAME:	TITLE:
NAME:	TITLE:
NAME:	TITLE:
NAME:	TITLE:

4.EXECUTION - REQUIRED: (SUBJECT TO PENALTY OF FALSE STATEMENT)

DATE (MM/DD/YYYY)

*NOTE: LLC’S MAY HAVE MANY MANAGERS/MEMBERS, HOWEVER ONLY UP TO THREE OF THOSE PROVIDED WILL BE SHOWN ON THE DATABASE. ADDITIONAL NAMES WILL BE AVAILABLE BY REQUESTING COPIES OF THE ORIGINAL FILING.

PAGE 2 OF 2

Rev. 7/2017

INTERIM NOTICE OF CHANGE OF MANAGER/MEMBER

LIMITED LIABILITY COMPANY-DOMESTIC & FOREIGN

C.G.S. §§34-247k(f)

INSTRUCTIONS

1.NAME OF LIMITED LIABILITY COMPANY: Please provide the complete name of the Limited Liability Company as it currently appears on the records of the Secretary of the State. If the notice is being filed by a foreign Limited Liability Company, such Limited Liability Company should provide the name under which it is currently authorized to transact business in Connecticut.

2.NEW MANAGER(S)/MEMBER(S) INFORMATION: Please print or type the full name of the Limited Liability Company's NEW manager(s) or member(s), their titles and their residence and business addresses. Complete street addresses, including a street number, street name, city, state, postal code and country if other than the United States, are required. NOTE: P.O. boxes are only acceptable as additional information.

3.MANAGER(S)/MEMBER(S) WHO HAVE CEASED TO BE MANAGER(S)/MEMBER(S): Please print or type the full name of Manager(s)/Member(s) who have ceased holding their position within the Limited Liability Company and their title(s) as they appear on our records. NOTE: Name and title(s) must match our records exactly otherwise changes will not be reflected. Be careful to include items such as Jr., Sr., middle initials, etc. Check Concord online for name of record. Individual/Entity will only be removed from those titles indicated, therefore, be sure to include all applicable titles.

4.EXECUTION: The document must be executed (signed) by an authorized official of the Limited Liability Company. That person must print or type his or her name and state the capacity under which he or she signs. The execution constitutes a legal statement under the penalties of false statement that the information provided in the document is true.

OFFICE OF THE SECRETARY OF THE STATE

MAILING ADDRESS:

COMMERCIAL RECORDING DIVISION

CONNECTICUT SECRETARY OF THE STATE

P.O. BOX 150470

HARTFORD, CT 06115-0470

DELIVERY ADDRESS:

COMMERCIAL RECORDING DIVISION CONNECTICUT SECRETARY OF THE STATE 30 TRINITY STREET

HARTFORD, CT 06106

PHONE: 860-509-6003

WEBSITE: www.concord-sots.ct.gov

INSTRUCTIONS

DO NOT SCAN THIS PAGE

Rev. 7/2017