MINNESOTA SECRETARY OF STATE APPLICATION OF FOREIGN CORPORATION FOR A CERTIFICATE OF WITHDRAWAL FROM MINNESOTA (Filing Fee $50) READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM 1. The name of the corporation is: 2. The corporation, which is a (List the state or country of the home jurisdiction) corporation authorized to transact business in Minnesota hereby applies for a Certificate of Withdrawal. This corporation has no property located in Minnesota and has ceased to transact business in Minnesota. The Board of Directors of the corporation has decided to surrender its authority to transact business in Minnesota and revokes the authority of its registered agent to accept service of process. 3. Any process that may be served upon the Secretary of State of Minnesota after the withdrawal of this corporation from Minnesota should be forwarded to: Name Address City State ZIP The corporation hereby promises to pay to the State Treasurer any additional fees found by the Secretary of State to be due and owing. 4. I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent of the person(s) whose signature would be required who has authorized me to sign this document on his/her behalf, or in both capacities. I further certify that I have completed all required fields, and that the information in this document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document under oath. (President, Vice-President, Secretary. Ass’t Sec’y, or Agent) 5. List a name, daytime phone number, & e-mail address of a person who can be contacted about this form. Contact Name Phone Number E-Mail Address ForeignCorpWithdrawalRev.09-29-10 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS Retain the original signed copy of this document for your records and submit a legible photocopy for filing with the Secretary of State. NOTE: This form is intended merely as a guide for filing and is not intended to cover all situations. 1. List the full legal name of the corporation used in Minnesota. 2. List the name of the state, province or country in which the entity was originally incorporated. 3. List the name and address of the individual or company to which service of process should be forwarded after the filing of this withdrawal application. 4. One of the following officers of the corporation must sign the document: president, vice-president, secretary, assistant secretary, or an Authorized Agent (The signing party must indicate on the document that they are acting as the agent of the person(s) whose signature would be required and that they have been authorized to sign on behalf of that person(s). 5. List a name, daytime telephone number and an e-mail address of a person who can be contacted about this form. The filing fee is $50.00 Payable to the MN Secretary of State FILE IN-PERSON OR MAIL TO: Minnesota Secretary of State - Business Services Retirement Systems of Minnesota Building 60 Empire Drive, Suite 100 St Paul, MN 55103 (Staffed 8:00 - 4:00, Monday - Friday, excluding holidays) To obtain a copy of a form you can go to our web site at www.sos.state.mn.us , or contact us between 9:00am to 4:00pm, Monday through Friday at (651) 296-2803 or toll free 1-877-551-6767. All of the information on this form is public. Minnesota law requires certain information to be provided for this type of filing. If that information is not included, your document may be returned unfiled. This document can be made available in alternative formats, such as large print, Braille or audio tape, by calling (651)296-2803/voice. For a TTY/TTD (deaf and hard of hearing) communication, contact the Minnesota Relay Service at 1-800-627-3529 and ask them to place a call to (651)296-2803. The Secretary of State's Office does not discriminate on the basis of race, creed, color, sex, sexual orientation, national origin, age, marital status, disability, religion, reliance on public assistance or political opinions or affiliations in employment or the provision of service. American LegalNet, Inc. www.FormsWorkFlow.com