Form 80.030 - Officer'S Statement printable pdf download

Form 80.030 - Officer'S Statement

Office Use Only:

DEAN HELLER

Officer’s

Secretary of State

Statement*

101 North Carson Street, Suite 3

Carson City, Nevada 89701-4786

(PURSUANT TO NRS 80.030)

(

775) 684 5708

Important: Read attached instructions before completing form.

- Remit in Duplicate -

1. Name of corporation (provide modified name also if filed pursuant to 80.025):

______________________________________________________________________________

(currently on file in Nevada)

______________________________________________________________________________

2. State of incorporation:__________________________________________________________

3. Changes reflected by filing of document:

(check the appropriate spaces and/or describe under "other")

______ Name

______ Stock

______ Purpose

______ Dissolution

______ Merger (if survivor is qualified in Nevada and the articles were amended within the merger)

______ Other (specify changes):

4. Signature (must be signed by an officer of the corporation):

________________________________________

__________________________

Signature of Officer Making Statement

Title of Officer

* Submit this form with either a certified copy of or a certificate evidencing the filing of any

document amendatory or otherwise relating to the original articles in the place of the corporations

creation.

IMPORTANT: Failure to include any of the above information and remit with the proper fees may

cause this filing to be rejected.

Nevada Secretary of State Form 80.030 OFFICER’S STATEMENT1999.01

Revised on: 03/07/00

Form 80.030 - Officer'S Statement