Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605)773-4845 APPLICATION FOR CERTIFICATE OF WITHDRAWAL FOREIGN NONPROFIT CORPORATION Please Type or Print Clearly in Ink Please submit one Original and one Photocopy FILING FEE: $5 payable to SECRETARY OF STATE Telephone # _______________________ FAX # _________________________ Pursuant to the provisions of the South Dakota Business Corporation Act, the undersigned corporation hereby applies for a Certificate of Withdrawal from South Dakota, and for that purpose submits the following statement: 1. The name of the corporation is _____________________________________________________________________ ______________________________________________________________________________________________ 2. State or country where incorporated _________________________________________________________________ 3. That this corporation is not doing or engaging in any business in this state, and hereby surrenders its authority to transact business in South Dakota. 4. It revokes the authority of its registered agent in your State to accept service of process, and consents that service of process in any action, suit or proceeding based upon any cause of action arising in your State during the time the corporation was authorized to transact business in your State may thereafter be made on the corporation by service thereof on the Secretary of State of your State. 5. The post-office address to which the Secretary of State may mail a copy of any process against the corporation that may be served on him is ______________________________________________________________________________________________ Post Office Address City State ZIP+4 To be signed in the presence of a notary public by either the chairman of the board of directors, or by the president or any other officer. Dated ____________________________ ______________________________________________ (Signature of an authorized officer) ______________________________________________ (Printed Name) ______________________________________________ (Title) STATE OF _____________________________ COUNTY OF ___________________________ On this the ___________ day of _________________________, 20 ____ before me personally appeared ____________________________________________________________ known to me or satisfactorily proven to be the person who is described in, and who executed the within instrument and acknowledged to me that she/he/they executed the same. _________________________________ My Commission Expires ______________________________________________ Notary Public nonprofitwithdrawal July 2008 American LegalNet, Inc. www.FormsWorkflow.com