Filing Fee $85.00 for domestic; $150.00 for foreign BUSINESS CORPORATION STATE OF MAINE AMENDED ANNUAL REPORT _____________________ Deputy Secretary of State ______________________________________ (Name of Corporation) Pursuant to 13-C MRSA §1623, the undersigned corporation executes and delivers the following Amended Annual Report: FIRST: The jurisdiction of its incorporation is ________________________________________________________________. SECOND: The original annual report was filed on (date) ___________________________________. THIRD: The information has changed as follows (attach additional pages, if necessary): ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ FOURTH: This information changed on (date) _______________________________. DATED _________________________ *By __________________________________________________ (authorized signature) __________________________________________________ (type or print name and capacity) • An amended annual report may be filed by the corporation to change information currently on file. The time for filing an amended annual report is from the date of the original filing until December 31st of that filing year. • If you are changing the officer, director or shareholder information, you must provide the name, title and complete physical address of this individual. Additionally, you must provide the information currently on file and indicate how it changed. *This document MUST be signed by any duly authorized officer OR the clerk. (13-C MRSA §121.5) Please remit your payment made payable to the Maine Secretary of State. SUBMIT COMPLETED FORMS TO: CORPORATE REPORTING SECTION, SECRETARY OF STATE, 101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101 FORM NO. MBCA-13A (1 of 1) Rev. 1/1/2005 TEL. (207) 624-7752 American LegalNet, Inc. www.USCourtForms.com