Version 1; 04-06-09 District of Columbia Government Corporations Division PO Box 92300 Washington DC 20090 Application and Petition for Reinstatement for Domestic Non-Profit Corporation Use this form to reinstate a domestic non-profit corporation in the District of Columbia. ENTITY TYPE FILING FEE Domestic Non-Profit Corporation $70, payable to DC Treasurer Pursuant to the provisions of Title 29, Chapter 3 of the Code of Laws of the District of Columbia, the undersigned domestic non-profit corporation hereby petitions and applies for a Certificate of Reinstatement of a proclaimed domestic non-profit corporation and hereby certifies as follows: 1. Entity Name at the time of proclamation: 2. New name that the corporation will be known as from now on. (If the Corporation name is available, you must use that name; if the name has been taken by another corporation, then you may choose a different name.) 3. The Certificate of Incorporation to transact business in the District of Columbia was revoked on September for failure and/or refusal to file reports for the reporting period or other reasons under DC Official Code (DCOC). nd (Revocation dates are always the 2 Monday of September of the revocation year) 4a. Registered Agent in the District of Columbia at the time of proclamation: 4b. That Registered Agent's address: 5. Attach any DCOC-required delinquent reports and filing fees and penalties. President / Vice-President Date Signature Secretary / Assistant Secretary Date Signature If you sign this application, you agree that you understand that anyone who makes a false statement anywhere on it can be punished by criminal penalties of a fine up to $1000, imprisonment up to 180 days, or both, under DCOC § 22-2405. Mail all forms and required payment to: Department of Consumer and Regulatory Affairs Corporations Division PO Box 92300 Washington, DC 20090 Phone: (202) 442-4400 For overnight delivery send to: Corporate Bank of America Attention: DC Government Wholesale Lockbox #92300 Mail Code MD4-301-18-04 225 North Calvert Street - 18th floor Baltimore, Maryland 21202 Please check dcra.dc.gov to view organizations required to register, to search business names, to get step-by-step guidelines to register an organization, to search registered organizations, and to download forms and documents. Just click on "Corporate Registrations." American LegalNet, Inc. www.FormsWorkFlow.com