Filing Fee $90.00 FOREIGN BUSINESS CORPORATION STATE OF MAINE APPLICATION OF WITHDRAWAL _____________________ Deputy Secretary of State A True Copy When Attested By Signature ______________________________________ (Name of Corporation) _____________________ Deputy Secretary of State Pursuant to 13-C MRSA §1521 or §1523, the undersigned foreign corporation executes and delivers the following Application of Withdrawal: FIRST: SECOND: THIRD: FOURTH: The jurisdiction of its incorporation is _______________________________________________________________. The date on which it was authorized to do business in the State of Maine is ________________________________. The foreign corporation is not transacting business in this State and that it surrenders its authority to transact business in this State. (For Foreign Corporation Upon Conversion to a Nonfiling Entity): The type of other entity to which the foreign business corporation has been converted is _______________________ _____________ and the jurisdiction whose laws govern its internal affairs is ________________________________. FIFTH: The foreign corporation revokes the authority of its registered agent to accept service 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 this State. The mailing address to which the Secretary of State may mail a copy of any process served on the Secretary of State: ______________________________________________________________________________________________. (street, city, state and zip code) SIXTH: The foreign corporation is committed to notify the Secretary of State in the future of any change in its mailing address. *By __________________________________________________ (signature of any duly authorized officer) DATED _________________________ __________________________________________________ (type or print name and capacity) *This document MUST be signed by any duly authorized officer. (13-C MRSA §121.5) Please remit your payment made payable to the Maine Secretary of State. SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE, 101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101 FORM NO. MBCA-12B (1 of 1) Rev. 8/1/2004 TEL. (207) 624-7752 American LegalNet, Inc. www.FormsWorkFlow.com Filer Contact Cover Letter To: Department of the Secretary of State Division of Corporations, UCC and Commissions 101 State House Station Augusta, ME 04333-0101 Tel. (207) 624-7752 Name of Entity (s): _______________________________________________________________________ _______________________________________________________________________ List type of filing(s) enclosed (i.e. Articles of Incorporation, Articles of Merger, Articles of Amendment, Certificate of Correction, etc.) Attach additional pages as needed. ________________________________________________________________________ ________________________________________________________________________ Special handling request(s): (check all that apply) Hold for pick up Expedited filing - 24 hour service ($50 additional filing fee per entity, per service) Expedited filing - Immediate service ($100 additional filing fee per entity, per service) Total filing fee(s) enclosed: $ ________________ Contact Information ­ questions regarding the above filing(s), please call or email: (failure to provide a contact name and telephone number or email address will result in the return of the erroneous filing (s) by the Secretary of State's office) ___________________________________ (Name of contact person) ___________________________________ (Daytime telephone number) ____________________________________________________ (Email address) The enclosed filing(s) and fee(s) are submitted for filing. Please return the attested copy to the following address: ______________________________________________________________________________ (Name of attested recipient) _____________________________________________________________________________________________ (Firm or Company) _____________________________________________________________________________________________ (Mailing Address) _____________________________________________________________________________________________ (City, State & Zip) American LegalNet, Inc. www.FormsWorkFlow.com