Filing Fee $25.00 NONPROFIT CORPORATION STATE OF MAINE STATEMENT OF INTENTION TO CARRY ON ACTIVITIES UNDER AN ASSUMED OR FICTITIOUS NAME _____________________ Deputy Secretary of State A True Copy When Attested By Signature ______________________________________ (Real Name of Corporation) _____________________ Deputy Secretary of State Pursuant to 13-B MRSA §308-A, the undersigned corporation executes and delivers the following Statement of Intention to Carry on Activities Under an Assumed or Fictitious Name: FIRST: The address of the registered office of the corporation in the State of Maine is ________________________________ ______________________________________________________________________________________________. (street, city, state and zip code) SECOND: ("X" one box only.) assumed name (13-B MRSA §308-A.1) fictitious name (13-B MRSA §308-A.2) The corporation intends to carry on activities under the assumed or fictitious name of ______________________________________________________________________________________________. Please note: A fictitious name is a name adopted by a foreign corporation authorized to carry on activities in this State because its real name is unavailable pursuant to 13-B MRSA §301-A. Complete the following if applicable: THIRD: If such assumed name is to be used at fewer than all of the corporation's places of activity in this State, the location(s) where it will be used is (are): ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ FORM NO. MNPCA-5 (1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com FOURTH: (Foreign Corporation Only) Jurisdiction of incorporation ______________________________________________________ and the date on which the corporation was authorized to carry on activities in Maine _____________________________________________ DATED _________________________ *By ___________________________________________________ (signature) __________________________________________________ (type or print name and capacity) *By ___________________________________________________ (signature) __________________________________________________ (type or print name and capacity) *This document MUST be signed by any duly authorized officer. (13-B MRSA §104.1.B) 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. MNPCA-5 (2 of 2) Rev. 9/16/2005 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