CERTIFICATE OF WITHDRAWAL FOREIGN CORPORATION APPLICATION SECRETARY OF STATE SFN 13101 (5-2012) FOR OFFICE USE ONLY System ID Number Work Order Number Filed By 1. FILING FEE $20.00 SEE INSTRUCTIONS FOR FEES, FILING AND MAILING INFORMATION. This form is prescribed for use by a foreign business corporation, a foreign professional corporation, or a foreign nonprofit corporation. The following statements are hereby submitted for Certificate of Withdrawal from the State of North Dakota. The Secretary of State may request any additional information necessary or appropriate to determine and assess any unpaid fees payable by the foreign corporation. TYPE OR PRINT LEGIBLY 2. Name of Corporation For reference, see North Dakota Century Code, Section 10-19.1-140 or 10-33-133. 3. Federal ID Number 4. State or Country Where Incorporated 5. Address to Which a Person May Mail a Copy of Any Process Against the Corporation: (Street/RR, PO Box, City, State, ZIP+4) 6. "The following is hereby affirmed: The corporation is not transacting business or conducting activities in North Dakota and surrenders its authority to do so. The corporation revokes the authority of its registered agent in North Dakota to accept service of process. The corporation consents to service of process on the corporation by service upon the North Dakota Secretary of State in any action, suit, or proceeding based upon any cause of action arising in North Dakota during the time the corporation was authorized to transact business or conduct activities. The corporation authorizes the Secretary of State to correct numbers 2 and 4 if not reflected as registered. The undersigned, a person authorized by the corporation to sign this application, knows the contents of the application, and believes the statements made to be true. I understand that if I make a false statement in this document, I may be subject to criminal penalties." Signature: Date Daytime Telephone Number and Extension, if any: 7. Name of Person to Contact About This Application E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com SFN 13101 (5-2012) Page 2 INSTRUCTIONS FOR CERTIFICATE OF WITHDRAWAL FOREIGN CORPORATION APPLICATION A foreign corporation may apply for a Certificate of Withdrawal when it ceases to transact business or conduct activities in the State of North Dakota. The Certificate of Withdrawal may invalidate any other licenses or permits the corporation may have acquired. The Secretary of State may request any additional information necessary or appropriate to determine and assess any unpaid fees payable by the foreign corporation. (The Secretary of State will advise a corporation if additional information is required when the application for Certificate of Withdrawal is reviewed.) The following numbers correspond to the numbered sections on the form. 1. FILING FEE: The application filing fee is $20.00. (A check must be payable to "Secretary of State" and must be for U.S. negotiable funds. Payments may also be made by credit card using Visa, MasterCard or Discover.) Provide the corporate name EXACTLY as provided in the Certificate of Authority or last Amended Certificate of Authority issued by the North Dakota Secretary of State. (Punctuation and abbreviations must be consistent with that as authorized.) If the name in number 2 is not the same as currently registered, the name will be corrected by the Secretary of State. To properly maintain corporate records, the Federal ID number is required. Privacy: In compliance with N.D.C.C., Section 10-19.1-149.1, social security numbers and Federal ID numbers are not disclosed to the public. They are used by the Secretary of State to maintain accurate corporate files. Therefore, while voluntary disclosure is requested, failure to do so will not result in rejection of the registration. 4. 5. 6. Identify the state or country in which the corporation is incorporated. If the state or country of origin in number 4 is not the same as currently registered, the state or country of origin will be corrected by the Secretary of State. Provide an address to which a person may mail a copy of any process against the corporation. In this section, an address must include a street or rural address, a post office box number if applicable, and the city, state, and ZIP code plus 4-digit extension. As required by North Dakota law, the application includes the following statements which are affirmed by signing the application: a) b) The corporation is not transacting business or conducting activities in North Dakota. The corporation revokes the authority of its registered agent in North Dakota. The corporation consents to service of process on the corporation by service upon the North Dakota Secretary of State in any action, suit, or proceeding based upon any cause of action arising in North Dakota during the time the corporation was authorized to transact business or conduct activities. The corporation authorizes the Secretary of State to correct numbers 2 and 4 if not correctly reflected. 2. 3. c) This application must be dated and bear the signature of an individual authorized to sign on behalf of the corporation. 7. Provide the name, email address, and daytime telephone number of a contact person if this office has any questions or needs additional information related to this application. The email address is not disclosed to the public; this information is privatized in accordance with N.D.C.C. Section 44-04-18.21. ASSISTANCE: If assistance is required to complete the application for Certificate of Withdrawal, contact the Secretary of State's Office. Email: Email is not a secure utility for the transmission of private information or credit card authorizations. DO NOT EMAIL YOUR DOCUMENT TO THE SECRETARY OF STATE. FAX FILING: Documents and Credit Card Payment Authorization may be faxed to 701-328-2992. A faxed filing does not expedite the process of the application in the office of the Secretary of State. MAILING INSTRUCTIONS: Send an application AND filing fee to: Secretary of State State of North Dakota 600 E Boulevard Ave Dept 108 Bismarck ND 58505-0500 Telephone: 701-328-2904 Toll Free: 800-352-0867 (ext. 8-2904) Fax: 701-328-2992 Web Site: http://www.nd.gov/sos CREDIT CARD PAYMENT AUTHORIZATION SECRETARY OF STATE SFN 51478 (4-2012) (All items required to complete transaction) Amount Authorized Name Address City State Telephone Number ZIP Code VISA Account Number MasterCard Discover CSC Number * Card Expires Month Y