New York State 
                                                                         Department of State 
                                                               DIVISION OF CORPORATIONS, 
                                                                         STATE RECORDS AND  
                                                               UNIFORM COMMERCIAL CODE 
                                                                         One Commerce Plaza 
                                                                         99 Washington Ave. 
                                                                         Albany, NY 12231-0001 
                                                                         https://dos.ny.gov                                         
DOCUMENT AND CERTIFICATE COVER SHEET 

Contact Information 
 
Name:   ______________________________________________________________________________ 
 
Mailing Address:_______________________________________________________________________ 
                   
              _____________________________________________________________________________ 
 
Email Address: ______________________________________________________________________ 
 
Phone Number:  ______________________________________________________________________ 
 
Request for Filing of Document 
 
Exact Name of Entity: __________________________________________________________ 
____________________________________________________________ 
 
Document Type:_______________________________________________________________  
                                   (i.e., Certificate of Incorporation, Articles of Organization, Certificate of Amendment, etc.): 
 
Request for Copies or Certificates of Status (Check the appropriate box) 
 
Exact Name of Entity: __________________________________________________________ 

□ Certified Copies of all Documents on File ($10 per document) 

□ Plain Copies of all Documents on File ($5 per document) 

□Certified Copy of _____________________________________________________ ($10 per document) 
                               (specify document) 

□ Plain Copy of ________________________________________________________ ($5 per document) 
                               (specify document) 

□ Certificate of Status - Long Form ($25 per document) 

□ Certificate of Status - Short Form ($25 per document)   
 
Method of Delivery of Filing Receipt or Other Document  

All documents will be returned to the email address listed above with the exception of certified and 
uncertified copies filed before July 1990. 

DOS-2183-f (04/22) 

                                                                                                        New York State 
                                                                                                        Department of State 
                                                                                                       DIVISION OF CORPORATIONS, 
                                                                                                        STATE RECORDS AND  
                                                                                                       UNIFORM COMMERCIAL CODE 
                                                                                                        One Commerce Plaza 
                                                                                                        99 Washington Ave. 
                                                                                                        Albany, NY 12231-0001 
                                                                                                        https://dos.ny.gov 
 
                            CERTIFICATE OF CHANGE  

                                            OF 
 
                                  (Insert Name of Foreign Limited Liability Company) 

                           Under Section 804-A of the Limited Liability Company Law 
 
 FIRST: The name of the foreign limited liability company is: 
  
                                                                                                                                                                               . 

 If applicable, the fictitious name the foreign limited liability company has agreed to use in this state is: 
  
                                                                                                                                                                               . 
  
 SECOND:  The application for authority was filed with 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 foreign limited liability company is 

      located, is changed to:                                                                                                                       . 
     
      The post office address to which the Secretary of State shall mail a copy of any process against the 
      foreign limited liability company served upon the Secretary of State by personal delivery is changed 
      to read in its entirety as follows: 
   
                                                                                                                                                                      . 
      The email address to which the Secretary of State shall email a notice of the fact that process against 
      the foreign limited liability company has been served electronically upon the Secretary of State is: 
                                                                                                                .  
      The email address to which the Secretary of State shall email a notice of the fact that process against 
      the foreign limited liability company has been served electronically upon the Secretary of State is 
      changed to read as follows: 
                                                                                                                .  
      The email address to which the Secretary of State shall email a notice of the fact that process against 
      the foreign limited liability company has been served electronically upon the Secretary of State is 
      deleted. 
   
 DOS-1362-f  (Rev. 12/22)                                                                                     Page 1 of 3 

          The foreign limited liability company hereby designates   
    
     its registered agent upon whom process against the foreign limited liability company may be served. 
     The street address of the registered agent is: 
       
                                                                                                                                                      . 
          The foreign limited liability company hereby changes the designation of its registered agent to:                                                               

                                                                                                                 .    
             The street address of the registered agent is: 

                                                                                                                 . 
          The foreign limited liability company hereby changes the address of its registered agent to: 

                                                                                                                                                                        . 
                   The foreign limited liability company hereby revokes the designation of its registered agent. 

  X                                                          Capacity of signer (Check appropriate box):         
                                   (Signature) 
                                                                    Member 
                                                                    Manager 
 
                                                                    Authorized Person 
   
                          (Type or Print Name) 
  
 DOS-1362-f  (Rev. 12/22)                                                                                              Page 2 of 3 

                                             CERTIFICATE OF CHANGE  
                                                            OF 
 
                                          (Insert Name of Foreign Limited Liability Company) 
 
                                 Under Section 804-A of the Limited Liability Company Law 
 
     Filer’s Name and Mailing Address: 

               Name: 

               Company, if Applicable: 

               Mailing Address: 

               City, State and Zip Code: 
  
 NOTES:  
 1. The name of the foreign limited liability company and the date of filing of the application for authority must exactly match the 
     records of the Department of State.  This information should be verified on the Department of State’s website at  
     https://dos.ny.gov.  
 2. This form was prepared by the New York State Department of State for filing a certificate of change by a foreign limited  
     liability company.  You are not required to use this form.  You may draft your own form or use forms available at legal supply  
     stores.   
 3. The Department of State recommends that legal documents be prepared under the guidance of an attorney.   
 4. The certificate must be submitted with a $30 filing fee made payable to the Department of State. 
   
 (For office use only) 
  
 DOS-1362-f  (Rev. 12/22)                                                                                                     Page 3 of 3