State of New Hampshire Filing fee: $25.00 Use black print or type. Form FNP-5 RSA 292:5b & RSA 293-A:15.20 APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF A FOREIGN NONPROFIT CORPORATION PURSUANT TO THE PROVISIONS OF VOLUNTARY CORPORATIONS AND ASSOCIATIONS AND THE NEW HAMPSHIRE BUSINESS CORPORATION ACT, THE UNDERSIGNED CORPORATION HEREBY APPLIES FOR A CERTIFICATE OF WITHDRAWAL FROM NEW HAMPSHIRE, AND FOR THAT PURPOSE SUBMITS THE FOLLOWING STATEMENT: FIRST: The name of the corporation is . SECOND: It is incorporated under the laws of . THIRD: It is not transacting business in New Hampshire. FOURTH: It hereby surrenders its authority to transact business in New Hampshire. FIFTH: It revokes the authority of its registered agent in New Hampshire to accept service 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 transact business in this state. SIXTH: The mailing address to which the Secretary of State may mail a copy of any process against the corporation that may be served on him is . SEVENTH: The corporation will notify the Secretary of State in the future of any change in its mailing address. (Note 1) (Corporate Name) (Note 2) (Signature) (Print or type name) (Note 2) (Title) Date signed: Notes: 1. Exact corporate name of corporation making the statement. 2. Signature and title of person signing for the corporation. Must be signed by chairman of the board of directors, president or another officer; or see RSA 293-A:1.20(f) for alternative signatures. DISCLAIMER: All documents filed with the Corporate Division become public records and will be available for public inspection in either tangible or electronic form. Mail fee and DATED AND SIGNED ORIGINAL to: Corporate Division, Department of State, 107 North Main Street, Concord NH 03301-4989. Form FNP-5 (4/2009) American LegalNet, Inc. www.FormsWorkFlow.com