APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF A FOREIGN CORPORATION CONNIE LAWSON SECRETARY OF STATE CORPORATIONS DIVISION 302 W. Washington St., Rm. E018 Indianapolis, IN 46204 T elephone: (317) 232-6576 State Form 39077 (R10 / 4-12) Approved by State Board of Accounts, 1995 INSTRUCTIONS: Use 8 1/2" x 11" white paper for attachments. Present original and one (1) 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. Indiana Code 23-1-50-2; 23-17-26-11 FILING FEE IS $30.00 APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF Name of corporation A FOREIGN CORPORATION ADMITTED TO TRANSACT BUSINESS IN THE STATE OF INDIANA The undersigned officer of ____________________________________________________________________________ (hereinafter referred to as the "Corporation"), which exists pursuant to the provisions of ____________________________ (state or country) as amended, desiring to effectuate the withdrawal of the Corporation from the State of Indiana, certifies the following facts: ARTICLE I - NAME Name of Corporation State or country in which it is incorporated ARTICLE II - REPRESENTATION BY THE WITHDRAWING CORPORATION The Corporation received its Certificate of Authority from the State of Indiana on (month, day, year) _______________________________ and is no longer transacting business in Indiana. The Corporation surrenders its authority to transact business in Indiana. ARTICLE III - SERVICE OF PROCESS The Corporation revokes the authority of _________________________________________________________________, its Registered Agent to accept service of process on its behalf and appoints the Secretary of State as its agent for service of process in any proceeding based on a cause of action arising during the time it was authorized to transact business in Indiana. A copy of any such process served on the Secretary of State should be mailed to the following address of the corporation: Address of Corporation (number and street, city, state, and ZIP code) The Corporation shall notify the Secretary of State in the future of any change in its mailing address. In witness whereof, the undersigned being the ___________________________________________________________ of Title said Corporation executes this Application for Certificate of Withdrawal 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