Mail all forms and required payment to: Department of Consumer and Regulatory Affairs Corporations Division PO Box 92300 Washington, DC 20090 Phone: (202) 442 - 44 32 Corporate Online Services Information: Many corporate filings are available by using CorpOnline Service. Go to CorpOnline site at https://corp online .dcra.dc.gov , create the profile, access the online services main page and proceed. Online filers must pay by using the credit card. District of Columbia Government Corporations Division Statement of Abandonment of A Plan of Conversion of Domestic & Foreign Filing Entity . Form G N - 12 , Ver. 2 , April 2018 . Use this form to abandon a plan/statement of conversion. This form can only be used before a statement of conversion becomes effective . The statement of abandonment shall be effective upon filing ENTITY TYPE FILING F E E Domestic & Foreign Filing Entity Refer to Corporate Fee Schedule posted online; Under the provisions of the Title 29 of D.C. Code (Business Organizations Act), the domestic filing entity listed below hereby applies for a Certificate of Abandonment and for that purpose submits the statement below. 1.1. The name of the converting entity . 2. The date on which the statement of conversion was filed. 3. The conversion has been a bandoned in accordance with section 247 29 - 20 4 .04. If you sign this form you agree that anyone who makes a false statement can be punished by criminal penalties of a fine up to $1000, imprisonment up to 180 days, or both, under DCOC 247 22 - 2405; 4 . Name of th e Governor or Authorized Person. 4A . Si gnature of the Governor or Authorized Person . 5 .Name of the Governor or Authorized Person. 5A . Signature of the Governor or Authorized Person. American LegalNet, Inc. www.FormsWorkFlow.com