APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY State Form 39034 (R10 / 4-12) Corporate Form No. 115 Approved by the State Board of Accounts, 2007 NOTE: An Original Certificate of Existence duly authenticated by the proper authority from the corporation’s domiciliary state within the last sixty (60) days must be submitted with this application. INSTRUCTIONS: 1. 2. 3. 4. CONNIE LAWSON SECRETARY OF STATE BUSINESS SERVICES DIVISION 302 W. Washington Street, Room E018 Indianapolis, Indiana 46204 Telephone: (317) 232-6576 Indiana Code 23-1-49-4; 23-17-26-4 Filing Fee: $ 30.00 Make check or money order payable to Secretary of State Use 8 1/2" x 11" white paper for attachments. Present original and one copy to address in upper right corner of this form. Please TYPE or PRINT. Please visit our office on the web at www.sos.in.gov. APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY OF Name of Corporation A FOREIGN CORPORATION ADMITTED TO TRANSACT BUSINESS IN INDIANA The undersigned officers of _________________________________________________________________________________ (hereinafter referred to as the "Corporation"), which exists pursuant to the provisions of the laws of _________________________ as amended, desire to obtain an Amended Certificate of Authority. 1. The above Corporation received a Certificate of Authority to transact business in the State of Indiana on the _____________ ARTICLE II - REPRESENTATION BY THE 20 _________ CORPORATION day of ___________________________________________ , WITHDRAWING . 2. The Corporation desires to change its corporate name in Indiana as follows: ___________________________________________________________________________________________________ 3. The Corporation has changed the period of its duration from ___________________________________________________ to ___________________________________________________. 4. The Corporation has changed the state or country of its incorporation from _______________________________________ to ______________________________________. 5. The Corporation has converted the entity type to a _________________________________________________________. In Witness Whereof, the undersigned, being the __________________________________________________________ of said Title Corporation executes this Application for Amended Certificate of Authority and verifies, subject to penalties of perjury, that the statements contained herein are true, this ____________ day of _______________________________________ , 20 ________. Signature Printed name American LegalNet, Inc. www.FormsWorkFlow.com