Looking for a Ct Tax Forms And Templates? Download it for free!

State of Connecticut

Form TPM-4

Notice of Appointment of Registered Agent and Registered Agent’s Statement

(Rev. 03/06)

Complete this form in black or blue ink only.

Sign, date, and return original to:

Office of the Attorney General

Finance Department

PO Box 120

Hartford CT 06141-0120

The undersigned Nonparticipating Manufacturer (NPM), __________________________________________________________, hereby

appoints_________________________________________________________________as its registered agent. Said registered agent

is authorized to receive service of process on behalf of the NPM. The NPM agrees to do the following: (1) provide notice to the Office

of the Attorney General of the State of Connecticut (Attorney General) at least 30 calendar days prior to termination of the authority of the

registered agent; and (2) provide proof to the satisfaction of the Attorney General of the appointment of a new agent at least five calendar

days prior to the termination of the existing agent appointment. The NPM further agrees that if the agent terminates its agency appointment,

the undersigned will provide notice to the Attorney General of the termination within five calendar days and will include proof to the

Attorney General of the appointment of a new agent.

I hereby certify and declare that all of the statements and information contained in this Notice of Appointment, including but not limited to

any accompanying statements or attachments, are true and complete and that I am a person authorized to bind the NPM making this

Notice of Appointment either under the laws of Connecticut or of the jurisdiction where the manufacturer resides or is organized. The

failure to file this form is a basis for removal of the undersigned NPM and its brand families from the Connecticut Directory.

This Notice of Appointment must be signed and dated in the presence of a notary public.

Signature of Authorized Representative for NPM: ________________________________________________________________

Authorized Representative (Print Name): _______________________________________________________________________

Title: ______________________________________________________________________________________________________

Principal Place of Business (physical address): _________________________________________________________________

State of

)

County of

)

Country of

)

On _____________________________________ , before me, _________________________________________________ ,

personally appeared _______________________________________________ , personally known to me (or proved to me on the basis

of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he or she

executed the same in his or her authorized capacity, and that by his or her signature on the instrument the person, or the entity upon

behalf of which the person acted, executed the instrument.

WITNESS my hand and official seal.

Signature ________________________________________________________________________________________________

My Commission expires: ____________________________________________________________________________________

IMPORTANT: Registered agents must complete and sign the statement on the back of this form.

Form Tpm-4 - Notice Of Appointment Of Registered Agent And Registered Agent'S Statement