Form BUS-012 "Interim Notice of Change of Officer/Director - Domestic or Foreign Corporations" - Connecticut

What Is Form BUS-012?

This is a legal form that was released by the Connecticut Secretary of the State - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Connecticut Secretary of the State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BUS-012 by clicking the link below or browse more documents and templates provided by the Connecticut Secretary of the State.

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Download Form BUS-012 "Interim Notice of Change of Officer/Director - Domestic or Foreign Corporations" - Connecticut

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Secretary of the
State of Connecticut
OFFICE USE ONLY
PHONE: 860-509-6003 • EMAIL: crd@ct.gov • WEB: www.concord-sots.ct.gov
INTERIM NOTICE OF CHANGE OF
• Use ink. • Print or type.
OFFICER/DIRECTOR
• Attach additional 8½ x 11 sheets if necessary.
DOMESTIC OR FOREIGN CORPORATIONS
FILING PARTY:
(confirmation will be sent to this address)
NAME:
FILING FEE: $20.00
ADDRESS:
Make checks payable to
“Secretary of the State”
CITY:
STATE:
ZIP:
1. COMPLETE NAME OF CORPORATION:
(required) (Must match our records exactly and include the business
designation (e.g. Inc., Co., Corp., etc.)
2. NEW OFFICER/DIRECTOR INFORMATION:
(New information must include name, title, residence and business
NOTE: Adding a new officer/director does not replace an existing officer/director. Proceed to section 3
addresses.)
to remove existing officer(s)/director(s), if applicable.
NAME:
TITLE:
CHECK IF DIRECTOR:
____________________________________________________________________________________________________________
BUSINESS ADDRESS:
RESIDENCE ADDRESS:
(No P.O. Box)
CHECK IF NONE:
(No P.O. Box)
STREET:
STREET:
CITY:
CITY:
STATE:
STATE:
ZIP:
ZIP:
NAME:
TITLE:
CHECK IF DIRECTOR:
_______________________________________________________________
_____________________________________________
BUSINESS ADDRESS:
RESIDENCE ADDRESS:
(No P.O. Box)
CHECK IF NONE:
(No P.O. Box)
STREET:
STREET:
CITY:
CITY:
STATE:
STATE:
ZIP:
ZIP
:
TITLE:
NAME:
CHECK IF DIRECTOR:
____________________________________________________________________________________________________________
RESIDENCE ADDRESS:
(No P.O. Box)
BUSINESS ADDRESS:
(No P.O. Box)
CHECK IF NONE:
STREET:
STREET:
CITY:
CITY:
STATE:
ZIP:
STATE:
ZIP:
PAGE 1 OF 2
BUS-012 (INTERIM NOTICE OF CHANGE OF CORPORATION OFFICERS/DIRECTORS)
REV. 11/2020
Secretary of the
State of Connecticut
OFFICE USE ONLY
PHONE: 860-509-6003 • EMAIL: crd@ct.gov • WEB: www.concord-sots.ct.gov
INTERIM NOTICE OF CHANGE OF
• Use ink. • Print or type.
OFFICER/DIRECTOR
• Attach additional 8½ x 11 sheets if necessary.
DOMESTIC OR FOREIGN CORPORATIONS
FILING PARTY:
(confirmation will be sent to this address)
NAME:
FILING FEE: $20.00
ADDRESS:
Make checks payable to
“Secretary of the State”
CITY:
STATE:
ZIP:
1. COMPLETE NAME OF CORPORATION:
(required) (Must match our records exactly and include the business
designation (e.g. Inc., Co., Corp., etc.)
2. NEW OFFICER/DIRECTOR INFORMATION:
(New information must include name, title, residence and business
NOTE: Adding a new officer/director does not replace an existing officer/director. Proceed to section 3
addresses.)
to remove existing officer(s)/director(s), if applicable.
NAME:
TITLE:
CHECK IF DIRECTOR:
____________________________________________________________________________________________________________
BUSINESS ADDRESS:
RESIDENCE ADDRESS:
(No P.O. Box)
CHECK IF NONE:
(No P.O. Box)
STREET:
STREET:
CITY:
CITY:
STATE:
STATE:
ZIP:
ZIP:
NAME:
TITLE:
CHECK IF DIRECTOR:
_______________________________________________________________
_____________________________________________
BUSINESS ADDRESS:
RESIDENCE ADDRESS:
(No P.O. Box)
CHECK IF NONE:
(No P.O. Box)
STREET:
STREET:
CITY:
CITY:
STATE:
STATE:
ZIP:
ZIP
:
TITLE:
NAME:
CHECK IF DIRECTOR:
____________________________________________________________________________________________________________
RESIDENCE ADDRESS:
(No P.O. Box)
BUSINESS ADDRESS:
(No P.O. Box)
CHECK IF NONE:
STREET:
STREET:
CITY:
CITY:
STATE:
ZIP:
STATE:
ZIP:
PAGE 1 OF 2
BUS-012 (INTERIM NOTICE OF CHANGE OF CORPORATION OFFICERS/DIRECTORS)
REV. 11/2020
OFFICE USE ONLY
3. OFFICER(S) / DIRECTOR(S) WHO HAVE CEASED TO HOLD OFFICE:
NOTE: Name and title must match our records exactly or changes will not be reflected. Be careful to include items such as Jr., Sr.,
middle initials, etc. Check the Secretary of the State’s business registry database (www.concord-sots.ct.gov) for name and title
of record. Individual/entity will only be removed from those titles indicated, therefore, be sure to include all applicable titles.
NAME:
TITLE:
CHECK IF DIRECTOR:
NAME:
TITLE:
CHECK IF DIRECTOR:
NAME:
TITLE:
CHECK IF DIRECTOR:
NAME:
TITLE:
CHECK IF DIRECTOR:
NAME:
TITLE:
CHECK IF DIRECTOR:
4. EXECUTION/SIGNATURE (required)
(Subject to penalties of false statement):
DATE SIGNED:
/
/
FULL NAME OF SIGNATORY
CAPACITY/TITLE OF SIGNATORY
SIGNATURE
PAGE 2 OF 2
BUS-012 (INTERIM NOTICE OF CHANGE OF CORPORATION OFFICERS/DIRECTORS)
REV. 11/2020
____________________________________________________________________________________________________
INTERIM NOTICE OF CHANGE OF OFFICER / DIRECTOR
CORPORATIONS - DOMESTIC & FOREIGN
INSTRUCTIONS
Numbers below correspond to the section numbers on the form.
1. NAME OF CORPORATION. Provide the complete name of the corporation as it currently appears on the
records of the Secretary of the State, including the business designation, (e.g., Inc., Corp, Incorporated,
etc). If the notice is being filed by a foreign corporation, provide the name under which the corporation is
currently authorized to transact business in Connecticut, exactly as it appears on the records of the
Connecticut Secretary of the State, including the business designation, (e.g., Inc. Corp., Corporation, etc.).
2. NEW OFFICER/DIRECTOR INFORMATION. Print or type the full names of new officers and directors,
their titles, and, if the person is a director, check the box following the statement "Check if Director." Provide
the residence and business addresses for each new officer/director listed. A complete street address is
required for each officer/director, including a street number, street name, city, state, postal code and
country if other than the United States. Note: P.O. boxes are only acceptable as additional information.
3. DIRECTORS/OFFICERS WHO HAVE CEASED TO HOLD OFFICE. Print or type the full names and titles
of directors/officers who have ceased holding their positions. If a person listed is a director, check the box
following the statement "Check if Director."
4. EXECUTION/SIGNATURE. The document must be executed/signed by an authorized official of the
corporation. That person must print or type their name and the capacity/title under which they execute/sign.
The execution/signature constitutes a legal statement under the penalties of false statement that the
information provided in the document is true.
OFFICE OF THE SECRETARY OF THE STATE
MAILING ADDRESS:
BUSINESS SERVICES DIVISION
CONNECTICUT SECRETARY OF THE STATE
P.O. BOX 150470
HARTFORD, CT 06115-0470
DELIVERY ADDRESS:
BUSINESS SERVICES DIVISION
CONNECTICUT SECRETARY OF THE STATE
165 CAPITOL AVENUE, SUITE 1000
HARTFORD, CT 06106
PHONE: 860-509-6003
WEBSITE:
www.concord-sots.ct.gov
____________________________________________________________________________________________________
INSTRUCTIONS
BUS-012 (INTERIM NOTICE OF CHANGE OF CORPORATION OFFICERS/DIRECTORS)
REV. 11/2020
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