DS-DE 41 Preserve Miami Beach REGISTERED AGENT OFFICE USE ONLY ^,
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STATEMENT OF APPOINTMENT
(Section 106.022, F.S.) 3�-
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® Original Appointment ❑ Change of Appointment c_, 71
❑ Change of Mailing Address ❑ Change of Physical Address =; c n
Registered Agent and Office Information
Name Telephone
S� a
Street Address
City � n � br- - State (, Zip Code 3� l 3
Mailing Address
City State Zip Code
accept this appointment and confirm that I am familiar with and accept the obligations of the position as set
forth in Section 106.022, F.S. I also understand that I may resign this appointment by executing a written
statement of resign tin d iling it with the applicable filing officer.
C .
Signature of R ed Agent Date
Former Registered Agent and Office Information (for changes only)
Name Telephone
Street Address
City State Zip Code
Committee or Organization Information
Name of Committee or Organization
Street Address Telephone
City State Zip Code � `3�
Signature of Chairpe s
Printed Name of Chairpersod Date
Form DS-DE 41 (revised 6/11)
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