FORM BCA 9.05 (rev. Dec. 2003) STATEMENT OF CANCELLATION OF NON-REISSUABLE SHARES Business Corporation Act Secretary of State Department of Business Services 501S. Second St., Rm. 350 Springfield, IL 62756 217-782-6961 www.cyberdriveillinois.com Remit payment in the form of a check or money order payable to Secretary of State. Print Reset Save ____________________________________ File #_____________________________ -------- Submit in duplicate -------- Type or Print clearly in black ink -------- Do not write above this line -------- Filing Fee: $5 Approved: ____________ 1. Corporate Name: ________________________________________________________________________________ 2. The Corporation has acquired and cancelled its own shares, and the Articles of Incorporation prohibit the re-issuance of such shares. 3. Number of shares cancelled and redemption or purchase price: ____________ Class Series Par Value Number of Shares Cancelled Redemption or Purchase Price Date of Cancellation _____________ ______________ ______________ ______________ ______________ 4. Number of authorized shares: Class BEFORE CANCELLATION Series Par Number Class AFTER CANCELLATION Series Par Number 5. Number of issued shares: 6. Paid-in capital: 7. The undersigned Corporation has caused this statement to be signed by a duly authorized officer who affirms, under penalties of perjury, that the facts stated herein are true and correct. All signatures must be in BLACK INK. Dated _______________________________ , _____ Month Day Year Any Authorized Officer's Signature Name and Title (type or print) $_________________________ $_________________________ ______________________________________ ______________________________________ ________________________________________________ Exact Name of Corporation NOTE: This form is applicable only where the Articles of Incorporation provide that shares redeemed or purchased shall be cancelled and shall not be re-issued. Upon such redemption and cancellation of shares, the paid-in capital of the Corporation is deemed to be reduced by that part of the paid-in capital which was represented by the shares so cancelled. The filing of this statement operates as an amendment to the Articles of Incorporation and reduces the number of shares of the class so redeemed which the Corporation is authorized to issue by the number of shares so redeemed and cancelled. Printed by authority of the State of Illinois. January 2015 - 1 - C 150.12 American LegalNet, Inc. www.FormsWorkFlow.com