State of New Hampshire No filing fee. Use black print or type. Form NP-5 RSA 292:10-a STATEMENT OF DISSOLUTION OF A NEW HAMPSHIRE NONPROFIT CORPORATION We, the undersigned, being the Treasurer and a majority of the Directors (or Trustees) of the above New Hampshire nonprofit corporation, with its principal place of business in , New Hampshire, do hereby certify that: 1. At a meeting of members or stockholders of said corporation held on , New Hampshire, a in or stockholders was adopted, of which the following is a true copy: , vote (Note l) of all the members 2. The plan for distribution of the corporation's assets and satisfaction of its obligations is as follows: Signed under the penalties of perjury. Signatures Type or Print Names Treasurer Director or Trustee Director or Trustee Director or Trustee Director or Trustee Director or Trustee Note 1. A CHURCH must have a UNANIMOUS vote and must state that all members eligible to vote voted dissolution. All OTHER NONPROFIT CORPORATIONS must have a TWO-THIRDS vote. (See RSA 292:10-a I and II) Mail DATED AND SIGNED ORIGINAL to: Corporate Division, Department of State, 107 North Main Street, Concord, NH 03301-4989. American LegalNet, Inc. www.FormsWorkFlow.com Form NP-5 (6/2009)