Office of the Minnesota Secretary of State Foreign Corporation or Cooperative | Certificate of Withdrawal Minnesota Statutes, Chapter 303 Read the instructions before completing this form. Filing Fee: $70 for expedited service in-person and online filings, $50 if submitted by mail 1. Name of Corporation in Home Jurisdiction: (Required) 2. Alternate Name used in Minnesota, if applicable: 3. Home Jurisdiction: (Required) 4. The corporation, authorized to transact business in Minnesota, hereby applies for a certificate of withdrawal. This corporation has no property located in Minnesota and has ceased to transact business in Minnesota. (Required) 5. The Board of Directors of the corporation has decided to surrender its authority to transact business in Minnesota and revokes the authority of its registered agent to accept service of process. 6. Any process that may be served upon the Secretary of State of Minnesota after the withdrawal of this corporation from Minnesota should be forwarded to: (Required) Name Address City State Zip Code 7. The corporation hereby promises to pay to the Commissioner of Management and Budget any additional license fees found by the Secretary of State to be due and owing. 8. I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent of the person(s) whose signature would be required who has authorized me to sign this document on his/her behalf, or in both capacities. I further certify that I have completed all required fields, and that the information in this document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document under oath. Signature of President, Vice Pres., Sec’y, Ass’t Sec’y or Authorized Agent Date Email Address for Official Notices Enter an email address to which the Secretary of State can forward official notices required by law and other notices: Check here to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law. List a name and daytime phone number of a person who can be contacted about this form: Contact Name Phone Number ForeignCorpWithdrawalRev.6/1/2012 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS File your business document online by visiting our website at www.sos.state.mn.us. This form is intended merely as a guide for filing and is not intended to cover all situations. Retain the original signed copy of this document for your records and submit a legible photocopy for filing with the Office of the Secretary of State. 1. List the entity name in the home jurisdiction on file with this office. 2. List the alternate name used in Minnesota, if any. 3. List the state or jurisdiction in which this organization is organized. 4. List the name and address of the individual or company to which service of process should be forwarded after the filing of this withdrawal application. 5. One of the following officers of the corporation must sign the document: President, Vice-President, Secretary, Assistant secretary, or an Authorized Agent (The signing party must indicate on the document that they are acting as the agent of the person(s) whose signature would be required and that they have been authorized to sign on behalf of that person(s). Email Address for Official Notices. This email address may be used to send annual renewal reminders and other important notices that may require action or response. Check the box if you wish to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law. List a name and daytime telephone number of a person who can be contacted about this form. Filing Fee: $70 for expedited service in-person and online filings, $50 if submitted by mail Payable to the MN Secretary of State Please submit all items together and mail to the address below: FILE IN-PERSON OR MAIL TO: Minnesota Secretary of State - Business Services Retirement Systems of Minnesota Building 60 Empire Drive, Suite 100 St Paul, MN 55103 (Staffed 8 a.m. – 4 p.m., Monday - Friday, excluding holidays) Phone Lines: (9 a.m. - 4 p.m., M-F) Metro Area 651-296-2803; Greater MN 1-877-551-6767 All of the information on this form is public. Minnesota law requires certain information to be provided for this type of filing. If that information is not included, your document may be returned unfiled. This document can be made available in alternative formats, such as large print, Braille or audio tape, by calling (651)296-2803/voice. For a TTY/TTD (deaf and hard of hearing) communication, contact the Minnesota Relay Service at 1-800-627-3529 and ask them to place a call to (651)296-2803. The Secretary of State's Office does not discriminate on the basis of race, creed, color, sex, sexual orientation, national origin, age, marital status, disability, religion, reliance on public assistance or political opinions or affiliations in employment or the provision of service. American LegalNet, Inc. www.FormsWorkFlow.com