Statement Of Resignation Of Registered Agent Form - Iowa Secretary Of State Page 2
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1
2INSTRUCTIONS
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 Office
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 your name.
5. State the date on which the resignation shall become effective.
6. Place an “X” in the appropriate box to indicate whether the registered office is also being discontinued.
7. Sign the statement.
8. Insert the date the statement was signed.
Certificate of Mailing
1. Insert your name.
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 office 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) 281-7142 or (515) 242-5953
Website:
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