DS-DE 41 UNITE HERE Miami Fund REGISTERED AGENT OFFICE USE ONLY
STATEMENT OF APPOINTMENT
m E! f :
(Section 106.022, F.S.)
IN Original Appointment ❑ Change of Appointment
❑ Change of Mailing Address ❑ Change of Physical Address
Registered Agent and Office Information
Name Telephone
Jacqueline Carmona (305) 283-4558
Street Address
9020 NE 8th Ave, Apt 2b
City State Zip Code
Miami FL 33138
Mailing Address
9020 NE 8th Ave, Apt 2b
City State Zip Code
Miami FL 33138
I accept this appointment and confirm that I am familiar with and accept the obligations of the position as set
forth in Section 106.0 .S. I also understand that I may resign this appointment by executing a written
statement o esignati% - d filing it with the applicable filing officer.
pow,' l (90 1 (v
S gnat - of Regis- -d 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
UNITE HERE Miami Fund
Street Address Telephone
275 Seventh Ave, 16th Floor (212) 265-7000
City State Zip Code
New York NY 10001
Signature of Chairperson
Donald Taylor kt\p..,(A1c7
Printed Name of Chairperson Date
Form DS-DE 41 (revised 6/11)