Prepare, sign, and submit with an original signature and filing fee. This is the minimum information required. STATE OF MONTANA (This space for Secretary of State use only) APPLICATION for CERTIFICATE of WITHDRAWAL of FOREIGN NONPROFIT CORPORATION 35-2-831, MCA MAIL: LINDA McCULLOCH Secretary of State P.O. Box 202801 Helena, MT 59620-2801 (406) 444-3665 (406) 444-3976 sos.mt.gov PHONE: FAX: WEB SITE: Required Filing Fee: $15.00 24 Hour Priority Handling check box and Add $20.00 1 Hour Expedite Handling check box and Add $100.00 Folder ID Number: _____________ The folder number begins with an "F" and may be Make checks payable to Secretary of State referenced at https://www.mtsosfilings.gov. If the document is hand written, please print legibly or the application may be denied. 1. 2. 3. The exact name of the Corporation: ___________________________________________________________________________ The state, tribe, or country of incorporation: ____________________________________________________________________ The Corporation is not transacting business in Montana and it surrenders its authority to transact business and conduct affairs in Montana. The Corporation revokes the authority of its registered agent in Montana to accept service of process 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 do business in Montana. Provide a business mailing address to which the Secretary of State may mail a copy of any process against the Corporation served on the Secretary of State: Business mailing address: ____________________________________________________________________________________ City: ____________________________________________ State: ______________________ Zip Code: ____________________ 6. 7. The Corporation will notify the Secretary of State should any other changes be made in its mailing address. OPTIONAL - The reason for filing this withdrawal:_________________________________________________________________ __________________________________________________________________________________________________________ 8. I, HEREBY SWEAR AND/OR AFFIRM, under penalty of law, including criminal prosecution, that the facts contained in this document are true. ___________________________________________________________________________ _____________________________ Signature of Presiding Officer of the Board of Directors, President, or other Officer Date ____________________________________________________________ Printed name 9. ___________________________________________ Date 4. 5. Daytime Contact: Phone __________________________________________Email _____________________________________ sos.mt.gov/Business/Forms 66-Foreign_Nonprofit_Corporation_Certificate_of_Withdrawal Revised: 09/2016 American LegalNet, Inc. www.FormsWorkFlow.com