Page 1 of 2 DOS - 1916 - f (Rev. 0 3 /1 6 ) CERTIFICATE OF AMENDMENT OF CERTIFICATE OF SURRENDER OF AUTHORITY OF (Insert Name of Foreign Corporation) Under Section 1311 of the Not-for-Profit Corporation Law FIRST: The name of the corporation is: . The fictitious name the corporation has agreed to use in New York State, if applicable, is: . SECOND: The jurisdiction of incorporation of the corporation is: . THIRD: The date the certificate of surrender of authority was filed with the Department of State is: . FOURTH: The changed address to which the Secretary of State shall mail a copy of any process against it served upon the Secretary of State is: . X (Signature) (Name of Signer) (Title of Signer) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 DOS - 1916 - f (Rev. 0 3 /1 6 ) CERTIFICATE OF AMENDMENT OF CERTIFICATE OF SURRENDER OF AUTHORITY OF (Insert Name of Foreign Corporation) Under Section 1311 of the Not-for-Profit Corporation Law Address City, State and Zip Code NOTES: 1. This form was prepared by the New York Department of State. You are not required to use this form. You may draft your own form or use forms available at legal stationery stores. 2. The Department of State recommends that all documents be prepared under the guidance of an attorney. 3. The certificate must be submitted with a $30 filing fee, made payable to the Department of State. For Office Use Only American LegalNet, Inc. www.FormsWorkFlow.com