FORM BCA 13.45 (rev. Dec. 2003) APPLICATION FOR WITHDRAWAL AND FINAL REPORT Business 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 #______________________________ -------- Submit in duplicate -------- Type or Print clearly in black ink -------- Do not write above this line -------- Filing Fee: $25 Approved: ___________ 1. Corporate Name: ________________________________________________________________________________ 2. State or Country of Incorporation: ___________________________________________________________________ 3. Post Office Address to which the Secretary of State may mail a copy of any process served upon it against the corporation: ______________________________________________________________________________________________ 4. No portion of the Corporation's issued shares at this time is represented by business transacted or property located in Illinois. 5. The Corporation surrenders its authority to transact business in Illinois. ______________________________________________________________________________________________ 6. The Corporation revokes the authority of its registered agent in Illinois to accept service of process, and hereby consents that service of process in any suit, action or proceeding based upon any cause of action arising in this State during the time this Corporation was licensed to transact business in this State may hereafter be made on such corporation by service thereof upon the Secretary of State. 7. a. List all issuances of shares not previously reported to the Secretary of State (including shares issued for cash or other property, share dividends, share splits, share exchanges pursuant to Section 11.10, and shares to effect an exchange or reclassification of issued shares), and give the value of the entire consideration received therefor, less expenses; list any amounts added or transferred to paid-in capital, without the issuance of shares. (See Note 1 on reverse.) or Contribution ____________ Date of Issuance Class _____________ Par Value ______________ Shares Issued ______________ Number of Received ______________ Entire Consideration (COMPLETE ONLY WHEN APPLICABLE) $_____________ $_____________ $_____________ TOTAL (COMPLETE BOTH SIDES OF DOCUMENT) Printed by authority of the State of Illinois. January 2015 - 1 - C 164.14 American LegalNet, Inc. www.FormsWorkFlow.com b. List all cancellations of shares not previously reported to the Secretary of State and give the cost. Date of Cancellation ______________ Class _______________ Number of Shares Cancelled ____________________ Cost ______________ $_____________ $_____________ $_____________ 8. Issued shares at date of execution: TOTAL Class Series Par Value Number of Shares ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 9. Paid-in capital at date of execution: ______________________________________________________________________________________________ 10. 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) Paid-in Capital $____________________ ("Paid-in Capital" replaces the terms "Stated Capital" and "Paid-in Surplus" and is equal to the total of these accounts.) ______________________________________ ______________________________________ ________________________________________________ Exact Name of Corporation 1. In the event of an increase in paid-in capital, all applicable franchise taxes, penalties and interest must be paid before this document can be accepted for filing. NOTE American LegalNet, Inc. www.FormsWorkFlow.com