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 Withdrawal on D issolution or Conversion to Non - filing Entity for Foreign Filing Entity Form F N - 4 , Ver. 2 , April 2018 . Use this form to withdraw foreign registration statement if foreign filing entity is being dissolved in the state of formation or if foreign filing entity is converting to non - filing entity (ex., unincorporated nonprofit association, and bank ). ENTITY TYPE / AU T H ORITY FILING F E E Foreign Filing Entity : 247 29 105.09. Refer to Corporate Fee Schedule posted online; Under the provisions of the Title 29 of D.C. Code (Business Organizations Act), the foreign filing entity listed below hereby applies for a Certificate of Withdrawal and for that purpose submits the statement below. 1.1. Foreign Entity Name. 2.Date of Issuance of Certificate of Foreign Registration. 3.Name of State / Country of Formation. 4.The type of entity that the foreign entity was before the dissolution or conversion. 5 . That the foreign entity surrenders its registration to do business in the District as a qualified entity . 6 . If the foreign entity has converted to a foreign non - filing entity answer 6 A - D : 6 A. The type of non - filing entity to which it has converted. 6 B. Name of State / Country whose laws govern converted non - 6 C. T he foreign entity revokes the authority of its registered agent to accept service on its behalf . 6 D . Address for the service of process. (Address that legal complaints can be forwarded to). 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; 7 . Name of the Governor or Authorized Person: 7A . Si gnature of the Governor or Authorized Person . American LegalNet, Inc. www.FormsWorkFlow.com