DOS - 1561 - f (Rev. 01 /1 8 ) Page 1 of 3 New York State Department of State DIVISION OF CORPORATIONS, STATE RECORDS AND UNIFORM COMMERCIAL CODE One Commerce Plaza 99 Washington Ave. Albany, NY 12231-0001 www.dos.ny.gov CERTIFICATE OF DISSOLUTION OF (Name of Corporation) Under Section 1003 of the Not-for-Profit Corporation Law FIRST: The name of the corporation is: . If the name of the corporation has been changed, the name under which it was formed is: SECOND: The certificate of incorporation was filed with the Department of State on: THIRD: The name and address of each officer and director of the corporation is: . FOURTH: The corporation is a: (check the appropriate box) charitable corporation non-charitable corporation. FIFTH: At the time of authorization of the corporation222s Plan of Dissolution and Distribution of Assets as provided in Not-for-Profit Corporation Law 2471002, the corporation holds: (Check the appropriate statement) assets which are legally required to be used for a particular purpose. no assets which are legally required to be used for a particular purpose. SIXTH: The corporation elects to dissolve. American LegalNet, Inc. www.FormsWorkFlow.com DOS - 1561 - f (Rev. 01 /1 8 ) Page 2 of 3 SEVENTH: (Check the appropriate statement) The dissolution was authorized by: a vote of a majority of the board of directors. The corporation has no members. the majority vote of the board of directors, followed by two-thirds vote of the members. EIGHTH: (Check the appropriate statement) Prior to the delivery of the Certificate of Dissolution to the Department of State for filing the Plan of Dissolution and Distribution of Assets was approved by the Attorney General. A copy of the approval of the Attorney General is attached. Prior to the delivery of the Certificate of Dissolution to the Department of State for filing the Plan of Dissolution and Distribution of Assets was approved by a Justice of the Supreme Court. A copy of the Court222s Order is attached. The corporation is a charitable corporation with no assets. Prior to the delivery of the Certificate of Dissolution to the Department of State for filing a copy of the Plan of Dissolution which contains the statement prescribed by paragraph (b) of Section 1001 of the Not-for-Profit Corporation Law, has been duly filed with the Attorney General. The corporation is a non-charitable corporation with no assets. The corporation222s Plan of Dissolution is not required to contain the statement prescribed by paragraph (b) of Section 1001 of the Not-for-Profit Corporation Law and is not required to be filed with Attorney General. X (Signature) (Print or Type Name of Signer) (Capacity of Signer) American LegalNet, Inc. www.FormsWorkFlow.com DOS - 1561 - f (Rev. 01 /1 8 ) Page 3 of 3 CERTIFICATE OF DISSOLUTION OF (Name of Corporation) Under Section 1003 of the Not-for-Profit Corporation Law Filer222s Name: Company, if applicable: Address: City, State and Zip Code: NOTES: 1. The name of the corporation and its date of incorporation provided on this certificate must exactly match the records of the Department of State. This information should be verified on the Department of State222s website at www.dos.ny.gov. 2. This Certificate of Dissolution must be signed by an officer, director or duly authorized person. 3. Attach the consent of the New York State Department of Taxation and Finance. 4. Attach the consent of the New York City Department of Finance, if required. 5. Attach a copy of the approval of the Attorney General or Order of the Supreme Court, if required. 6. The Certificate of Dissolution must include the approval of the Attorney General if the corporation is a charitable corporation or if the corporation is a non-charitable corporation and holds assets at the time of dissolution legally required to be used for a particular purpose. 7. Attach any other consent or approval required by law. 8. The fee for filing this certificate is $30, made payable to the Department of State. For DOS Use Only American LegalNet, Inc. www.FormsWorkFlow.com