Filing Fee $35.00 FOREIGN NONPROFIT CORPORATION STATE OF MAINE STATEMENT OF ABANDONMENT OF DOMESTICATION AND CONVERSION _____________________ Deputy Secretary of State A True Copy When Attested By Signature ______________________________________ (Name of Corporation) _____________________ Deputy Secretary of State Pursuant to 13-C MRSA §944, the undersigned corporation executes and delivers the following Statement of Abandonment of Domestication and Conversion: The domestication and conversion of this foreign nonprofit corporation in this State is abandoned in accordance with the laws of the foreign jurisdiction after articles of domestication and conversion have been filed with the Secretary of State. This statement takes effect upon filing, and the domestication and conversion is considered abandoned and does not become effective. FIRST: SECOND: DATED _________________________ *By ___________________________________________________ (signature of an officer or other duly authorized representative) __________________________________________________ (type or print name and capacity) *This document MUST be signed by an officer or other duly authorized representative. (§944) 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-19A 7-1-2003 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