FORM NFP 113.45 (rev. Dec. 2003) APPLICATION FOR WITHDRAWAL AND FINAL REPORT General Not For Profit Corporation Act Foreign Corporations Secretary of State Department of Business Services 501 S. Second St., 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: $5 Approved: ___________ 1. Corporate Name: ________________________________________________________________________________ 3. The Corporation surrenders its authority to conduct affairs in Illinois. 2. State or Country of Incorporation: ___________________________________________________________________ 4. The Corporation revokes the authority of its Registered Agent in Illinois to accept services 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 conduct affairs in this State may hereafter be made on such Corporation by service thereof upon the Secretary of State. 5. Post Office Address to which the Secretary of State may mail a copy of any process served upon it against the Corporation: ____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 6. 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. Dated _______________________________ , _____ Month Day Year Any Authorized Officer's Signature Name and Title (type or print) All signatures must be in BLACK INK. ______________________________________ ______________________________________ ________________________________________________ Exact Name of Corporation Printed by authority of the State of Illinois. January 2015 - 1 - C 161.11 American LegalNet, Inc. www.FormsWorkFlow.com