COMMONWEALTH OF KENTUCKY TREY GRAYSON, SECRETARY OF STATE ____________________________________________________________________________________________________________________________ Division of Corporations Business Filings PO Box 718 Frankfort, KY 40602 (502) 564-3490 www.sos.ky.gov Certificate of Withdrawal FCW (Foreign Corporation) ____________________________________________________________________________________________ Pursuant to the provisions of KRS Chapter 271B, 273 or 274, the undersigned hereby applies for a certificate of withdrawal on behalf of the corporation named below and, for that purpose, submits the following statements: 1. The corporation is a profit corporation (KRS 271B) a nonprofit corporation (KRS 273) a professional service corporation (KRS 274) 2. The name of the corporation is ________________________________________________________________________. (The name of the corporation or fictitious name adopted for use in Kentucky.) 3. The state or country of incorporation is__________________________________________________________________. 4. The corporation received authority to transact business in Kentucky on_________________________________________. 5. The corporation is not transacting business in Kentucky. 6. The corporation hereby surrenders the authority to transact business in Kentucky. 7. The corporation hereby revokes the authority of its registered agent in Kentucky to accept service of process on its behalf and hereby appoints the Secretary of State as its agent for service of process in any proceeding based upon any cause of action arising during the time it was authorized to transact business in Kentucky. 8. The street address to which the Secretary of State may mail a copy of any process served is: ___________________________________________________________________________________________________ Street Address (No P.O. Box Numbers) City State Zip Code 9. The corporation hereby commits to notify the Secretary of State in the future of any change in the mailing address set forth in question 8 above. 10. This application will be effective upon filing, unless a delayed effective date and/or time is provided. The effective date or the delayed effective date cannot be prior to the date the application is filed. The date and/or time is __________________. (Delayed effective date and/or time) I declare under penalty of perjury under the laws of the state of Kentucky that the foregoing is true and correct. ___________________________________________________________________________________________________ Signature of Authorized Party Printed Name & Title Date (08/10) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS CERTIFICATE OF WITHDRAWAL TYPE OF CORPORATION The corporation must indicate if it is a business corporation (KRS 271B), a nonprofit corporation (KRS 273), or a professional service corporation (KRS 274) by checking the appropriate box. NAME Use the exact name of the business entity as registered on file with the Office of the Secretary of State. DATE AUTHORIZED State the date that the business entity first received authority to transact business in Kentucky. DOCUMENT DELIVERY All documents will be sent to the return address on the outer envelope. If no address is found, the documents will be sent to the principal office. If the applicant wishes for correspondence from the Office of the Secretary of State to be sent to someone other than those above, a request must be submitted in writing affirming that request. All other communication and notification shall follow the process prescribed in Kentucky Revised Statute. EFFECTIVE DATE AND TIME/DELAYED EFFECTIVE DATE AND TIME The document will be effective on the date and time of filing, unless a delayed effective date and/or time is specified. The effective date or the delayed th effective date cannot be prior to the date the application is filed. A delayed effective date may not be later than the 90 day after the date of filing. WHO MAY SIGN The document must be signed by an officer or chairman of the board. NUMBER OF COPIES If filing via mail or in person, one exact or conformed copy of the documents with the filing fee must be submitted to the address below. To make a copy of the filing for delivery to the local county clerk’s office, visit www.sos.ky.gov and print a copy from the organization search tool. FILING FEE The filing fee for a profit corporation or a professional service corporation is $40.00. The filing fee for a nonprofit corporation is $8.00. Checks should be made payable to the "Kentucky State Treasurer." MAILING ADDRESS Trey Grayson Office of the Secretary of State P. O. Box 718 Frankfort, KY 40602-0718 OFFICE LOCATION Room 154, Capitol Building 700 Capital Avenue Frankfort, KY 40601 Hours of Operation: 8:00 AM-4:30 PM ET CONTACT INFORMATION If you have any questions, please feel free to visit our website at www.sos.ky.gov or call 502-564-3490. (08/10) American LegalNet, Inc. www.FormsWorkFlow.com