FORM NFP 113.40 (rev. Dec. 2003) APPLICATION FOR AMENDED AUTHORITY TO CONDUCT AFFAIRS IN ILLINOIS (Foreign Corporations) General Not For Profit Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-6961 www.cyberdriveillinois.com Remit payment in the form of a check or money order payable to Secretary of State. Print Reset Save ____________________________________ File #_____________________________ 1. Corporate Name: ________________________________________________________________________________ If a Change of Name is being Reported, the New Corporate Name: ________________________________________ Assumed Corporate Name (Complete only if the new corporate name is not available in this state.): -------- Submit in duplicate -------- Type or Print clearly in black ink -------- Do not write above this line -------- Filing Fee: $25 Approved: ___________ 2. a. State or Country of Incorporation: _________________________________________________________________ 3. If changed, Purpose(s) for which it is organized and proposes to pursue in the conduct of affairs in this State. For more space, use reverse side or attach additional sheets of this size. b. If changed, Period of Duration: ___________________________________________________________________ ______________________________________________________________________________________________ By electing this assumed name, the Corporation hereby agrees NOT to use its corporate name in the transaction of business in Illinois. Form NFP 104.15 is attached. 5. The undersigned Corporation has caused this statement to be signed by a duly authorized officer who affirms, under penalties of perjury, that the facts stated herein are true and correct. All signatures must be in BLACK INK. Dated _______________________________ , _____ Month Day Year Any Authorized Officer's Signature Name and Title (type or print) 4. This application is accompanied by a copy of the Articles of Amendment to the Articles of Incorporation, if any, as evidence of any change of name, duration or purpose reported herein, such copy being duly authenticated by the proper officer of the State or Country wherein the corporation is incorporated, which certification is not more than 90 days old. ______________________________________ ______________________________________ ________________________________________________ Exact Name of Corporation Printed by authority of the State of Illinois. January 2015 -- 1M -- C 218.9 American LegalNet, Inc. www.FormsWorkFlow.com