SECRETARY OF THE STATE OF CONNECTICUT MAILING ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, P.O. BOX 150470, HARTFORD, CT 06115-0470 DELIVERY ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, 30 TRINITY STREET, HARTFORD, CT 06106 PHONE: 860-509-6003 WEBSITE: www.concord-sots.ct.gov APPLICATION FOR CERTIFICATE OF WITHDRAWAL FOREIGN CORPORATION USE INK. COMPLETE ALL SECTIONS. PRINT OR TYPE. ATTACH 81/2 X 11 SHEETS IF NECESSARY. FILING PARTY (CONFIRMATION WILL BE SENT TO THIS ADDRESS): NAME: ADDRESS: FOR OFFICIAL USE ONLY: CITY: STATE: ZIP: 1. NAME OF CORPORATION IN ITS STATE/COUNTRY OF FORMATION: 2. IF DIFFERENT FROM THE ABOVE, THE NAME UNDER WHICH CORPORATION TRANSACTS BUSINESS IN CONNECTICUT: 3. STATE OR COUNTRY OF INCORPORATION: THE CORPORATION IS NOT TRANSACTING BUSINESS/CONDUCTING AFFAIRS IN CONNECTICUT AND SURRENDERS ITS AUTHORITY TO TRANSACT FURTHER BUSINESS/CONDUCT AFFAIRS THEREIN. THE CORPORATION REVOKES THE AUTHORITY OF ITS REGISTERED AGENT TO ACCEPT SERVICE OF PROCESS ON ITS BEHALF. THE CORPORATION APPOINTS THE SECRETARY OF THE STATE AS ITS AGENT FOR SERVICE OF PROCESS AND CONSENTS TO SERVICE OF PROCESS THEREON IN ANY ACTION, SUIT OR PROCEEDING BASED ON A CAUSE OF ACTION ARISING DURING THE TIME IT WAS AUTHORIZED TO TRANSACT BUSINESS/CONDUCT AFFAIRS IN THIS STATE. 4. THE ADDRESS TO WHICH THE SECRETARY OF THE STATE MAY MAIL ANY PROCESS SERVED UPON HIM IN ACCORDANCE WITH THE ABOVE STATED APPOINTMENT: ADDRESS: CITY: STATE: ZIP: THE CORPORATION AGREES TO NOTIFY THE SECRETARY OF THE STATE IN THE FUTURE OF ANY CHANGES TO THE ABOVE STATED ADDRESS. PAGE 1 OF 2 FORM CFWN-1-1.0 Rev. 7/2015 American LegalNet, Inc. www.FormsWorkFlow.com 5. EXECUTION: I HEREBY DECLARE UNDER THE PENALTIES OF FALSE STATEMENT THAT THE STATEMENTS MADE IN THE FOREGOING APPLICATION ARE TRUE. DATED THIS NAME OF SIGNATORY DAY OF CAPACITY/TITLE OF SIGNATORY , 20 SIGNATURE PAGE 2 OF 2 FORM CFWN-1-1.0 Rev. 7/2015 American LegalNet, Inc. www.FormsWorkFlow.com WITHDRAWAL OF FOREIGN CORPORATION (Stock or Nonstock Corporation) COMPLETING THE APPLICATION FOR CERTIFICATE OF WITHDRAWAL A foreign corporation authorized to transact business in Connecticut may withdraw its Certificate of Authority by filing an Application for Certificate of Withdrawal. The withdrawing corporation must appoint the Secretary of the State as its agent for service of process for matters relating to its activities in this state prior to withdrawal. It must further commit to notify the Secretary of the State of any changes to the address to which it would have copies of legal process sent following withdrawal. Instructions Correspond With Numbered Entries On The Form 1. NAME OF CORPORATION IN STATE OR COUNTRY OF FORMATION: Please provide the complete name of the corporation. 2. IF DIFFERENT FROM THE ABOVE, THE NAME UNDER WHICH THE CORPORATIONTRANSACTS BUSINESS IN CONNECTICUT: Please provide the complete name which the corporation transacts business in this state if it is different from the name under which it is incorporated. 3. STATE OR COUNTRY OF INCORPORATION: Please provide the corporation's state or country of incorporation. 4. THE MAILING ADDRESS TO WHICH THE SECRETARY OF THE STATE MAY MAIL ANY PROCESS SERVED UPON HIM IN ACCORDANCE WITH THE ABOVE STATED APPOINTMENT: Please provide a complete address. Note: It is the corporation's responsibility to file notices of any changes to this address following withdrawal. 5. EXECUTION: The document must be executed by an authorized official of the corporation. That person must print or type their name, state the capacity under which they sign and provide a signature. The execution 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: COMMERCIAL RECORDING DIVISION CONNECTICUT SECRETARY OF THE STATE P.O. BOX 150470 HARTFORD, CT 06115-0470 DELIVERY ADDRESS: COMMERCIAL RECORDING DIVISION CONNECTICUT SECRETARY OF THE STATE 30 TRINITY STREET HARTFORD, CT 06106 PHONE: 860-509-6003 WEBSITE: www.concord-sots.ct.gov INSTRUCTIONS DO NOT SCAN THIS PAGE FORM CFWN- 1-1.0 Rev. 7/2015 American LegalNet, Inc. www.FormsWorkFlow.com