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 Domestic Corporation) 
 
                           Under Section 803-A of the Not-for-Profit Corporation Law 
 
 FIRST: The name of the corporation is: 
 
 If the name of the corporation has been changed, the name under which it was formed is: 
 
 SECOND: The certificate of incorporation was filed by 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 corporation is 
       located, is changed to:                                                                                                                   . 
       The post office address to which the Secretary of State shall mail a copy of any process against 
  the corporation 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 corporation 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 corporation 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 corporation has been served electronically upon the Secretary of State is deleted. 

 DOS-1562-f  (Rev. 01/23)                                                                              Page 1 of 2 

         The corporation hereby designates   

               its registered agent upon whom process against the corporation may be served. 
               The street address of the registered agent is: 
  
                                                                                                                                                                . 
         The corporation hereby changes the designation of its registered agent to:                                                               
                                                                                                                             .  
         The street address of the registered agent is: 

                                                                                                                             . 
         The corporation hereby changes the address of its registered agent to: 

                                                                                                                                                                . 
         The corporation hereby revokes the designation of its registered agent. 

 FOURTH: The change was authorized by the board of directors. 
 
             X 
                          (Signature)                                            (Name of Signer) 
 
                                                                                 (Title of Signer) 
                                      CERTIFICATE OF CHANGE 
                                                    OF 
 
                                       (Insert Name of Domestic Corporation) 
 
                            Under Section 803-A of the Not-for-Profit Corporation Law 
 
 Filer’s Name:   

 Address: 

 City, State and Zip Code: 
 
 NOTES:  
 1. The name of the corporation and its date of incorporation provided on this certificate 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. You are not required to use this form. You  
     may draft your own form or use forms available at legal stationery stores.  
 2. The Department of State recommends that all documents be prepared under the guidance of an attorney.  
 3. The certificate must be submitted with a $20 filing fee. 
 
 For Office Use Only 

 DOS-1562-f  (Rev. 01/23)                                                                                           Page 2 of 2