District of Columbia Government Corporations Division Application for Certificate of Withdrawal for Foreign Non-Profit Corporation Form FNP-4, Version 2, July 2010. Use this form (FNP-4) to withdraw a foreign non-profit corporation from the District of Columbia. ENTITY TYPE Foreign Non-Profit Corporation FILING FEE Refer to Corporate Fee Schedule posted online; Under the provisions of the Non-Profit Corporation Act, DC Official Code (DCOC) Title 29 Chapter 3, the corporation below applies for a Certificate of Withdrawal from the District of Columbia. 1. Entity Name: 2. State or country whose laws govern Entity's incorporation: 3. By signing this form, you affirm that the Corporation: • Is not transacting business in the District of Columbia and surrenders its authority to transact business in the District. • Revokes the authority of its Registered Agent in the District to accept service of process and consents that that service in any suit, action or proceeding based on any cause of action in the District while the corporation was authorized to transact business in the District, may from now on -- be made on the corporation by service on the DC Superintendent of Corporations. 4. Mailing address where the Superintendent of Corporations may mail any process against the corporation it may be served: (must be corporation's main office address). 5. Select corporate officer executing this form: President Vice-President 7. Select corporate officer executing this form: Secretary 6. Signature: 8. Signature: Assistant Secretary 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 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