F The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth FPC One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Foreign Certi? cate of Withdrawal FORM MUST BE TYPED Upon Conversion to a Non? ling Entity (General Laws Chapter 156D, Section 15.22; 950 CMR 113.52) (1) Exact name of corporation: ___________________________________________________________________________ (2) Jurisdiction of incorporation: __________________________________________________________________________ (3) Type of other entity into which it has conver ___________________________________________________________ted: (4) Jurisdiction upon conversion: _________________________________________________________________________ (5) If the foreign business corporation has been converted into a foreign other entity: (a) h e corporation revokes the authority of its registered agent to accept service on its behalf. (b) h e Secretary of the Commonwealth is hereby appointed 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 the commonwealth. (6) h e corporations mailing address to which the Division may mail a copy of any process served on it: ________________________________________________________________________________________________ (number, street, city or town, state, zip code) (7) h e corporation shall notify the Division of any future changes to the above mailing address by ?ling a certi? cate of amendment. (8) h e corporation hereby certi? es that all taxes known to be due the commonwealth have been paid or provided for. (9) h is certi? cate is e ) ective at the time and on the date approved by the Division, unless a later e ) ective date not more than 90 days from the date of ? ling is speci? ed: __________________________________________________________________ Signed by: ___________________________________________________________________________________________, (signature of authorized individual) Chairman of the board of directors, President, Other o cer, Court-appointed ? duciary, on this _________________________day ofday ofday of__________________________________________________________________________________, _____________________. American LegalNet, Inc.P.C. www.USCourtForms.comc156ds1522950c11352 01/13/05>>>> 2 COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 Foreign Certi? cate of Withdrawal Upon Conversion to a Non? ling Entity (General Laws Chapter 156D, Section 15.22; 950 CMR 113.52) I hereby certify that upon examination of this foreign certi? cate withdrawal, duly submitted to me, it appears that the provisions of the General Laws relative thereto have been complied with, and I hereby approve said certi? cate; and the ? ling fee in the amount of $ ___________________________________________________ having been paid, said certi? cate is deemed to have been ? led with me this _____________day ofday ofday of __________________________, 20______ , at _______a.m./p.m. time E ) ective date: _____________________________________________________ (must be within 90 days of date submitted) WILLIAM FRANCIS GALVIN Secretary of the Commonwealth Filing fee: $100 Examiner # A.R. TO BE FILLED IN BY CORPORATION Contact Information: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Telephone: ___________________________________________________ Email: ______________________________________________________ Upon ? ling, a copy of this ? ling will be available at www.sec.state.ma.us/cor. If the document is rejected, a copy of the rejection sheet and rejected document will be available in the rejected queue. American LegalNet, Inc. www.USCourtForms.com