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 Dissolution for Domestic Limited Cooperative Association Form D L CA - 4 , Ver. 2 , April 201 8 . ENTITY TYPE / AUTHORITY FILING F E E Domestic Limited Cooperative Association : 247 29 1012.11. 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 Certificate of Dissolution and for that purpose submits the statement below. 1. Association Name. 2. The date of filing of the association's initial articles . 3 . The date the association dissolved or will dissolve . 4. Miscellaneous Provision. 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; 5 .Name of the Governor or Authorized Person. 5 A. Signature of the Governor or Authorized Person. American LegalNet, Inc. www.FormsWorkFlow.com