CERTIFICATE OF WITHDRAWAL APPLICATION FOREIGN LIMITED LIABILITY COMPANY SECRETARY OF STATE SFN 51989 (01-2016) For Office Use Only ID Number: WO Number: Filed: By: 1. FILING FEE: $20.00 SEE INSTRUCTIONS FOR FEE, FILING, AND MAILING INFORMATION. This form is prescribed for use by a foreign limited liability company or a foreign professional limited liability company. The following statements are hereby submitted for Certificate of Withdrawal from the State of North Dakota. TYPE OR PRINT LEGIBLY 2. Name of limited liability company 3. Federal ID Number 4. State or country where organized For reference, see North Dakota Century Code, Section 10-32.1-81. 5. Address to which a person may mail a copy of any process against the limited liability company (must be a complete MAILING address) 6. "The following is hereby affirmed by the undersigned: · The limited liability company is not transacting business or conducting activities in North Dakota and surrenders its authority to do so. · The limited liability company revokes the authority of its registered agent in North Dakota to accept service of process. The limited liability company consents to service of process on the limited liability company 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 limited liability company was authorized to transact business or conduct activities. · I authorize the Secretary of State to correct numbers 2 and 4 if not correctly reflected. · I am authorized by the limited liability company to sign this application, know the contents of the application, and believe 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 7. Name of person to contact about this document Email Address Date Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com SFN 51989 (01-2016) Page 2 of 2 INSTRUCTIONS FOR CERTIFICATE OF WITHDRAWAL APPLICATION - FOREIGN LIMITED LIABILITY COMPANY A foreign limited liability company 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 limited liability company may have acquired. The following numbers correspond to the numbered sections on the form. 1. FILING FEE: The application filing fee is $20.00. Checks 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, Discover, or American Express.) 2. Provide the limited liability company name as provided in the Certificate of Authority issued by the North Dakota Secretary of State or as last amended and filed with the Secretary of State. (Punctuation and abbreviations must be consistent as authorized.) If the name in number 2 is not reflected as authorized, the name will be corrected by the Secretary of State when the document is reviewed. 3. To properly maintain limited liability company records, the Federal ID number is requested. Privacy: In compliance with N.D.C.C., Section 10-32.1-95, social security numbers and Federal ID numbers are not disclosed to the public. Theyare used by the Secretary of State to maintain accurate limited liability company files. Therefore, while voluntary disclosure is requested, failure to do so will not result in rejection of the registration. 4. Identify the state or country in which the limited liability company is organized. If the state or country of origin in number 4 is not reflected as authorized, the state or country of origin will be corrected by the Secretary of State when the document is reviewed. 5. Provide a complete mailing address to which a person may mail a copy of any process against the limited liability company. 6. As required by North Dakota law, the application includes the following statements which are affirmed by signing the application: a. The limited liability company is not transacting business or conducting activities in North Dakota. b. The limited liability company revokes the authority of its registered agent in North Dakota. The limited liability company consents to service of process on the limited liability company 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 limited liability company was authorized to transact business or conduct activities. c. The Secretary of State is authorized to correct numbers 2 and 4. d. The signer is properly authorized to sign the application. This application must be dated and bear the signature of an individual authorized to sign on behalf of the limited liability company. 7. Provide the name, email address, and daytime telephone number of the person to contact for any issues 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, call (701) 328-2904. 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. 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. 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 (option 3) Fax: (701) 328-2992 Website: sos.nd.gov CREDIT CARD PAYMENT AUTHORIZATION SECRETARY OF STATE SFN 51478 (01-2016) Amount . Name Address Card Type City State Telephone Number ZIP Code Signature (required by credit card companies) Visa Account Number MasterCard Discover American Express CSC Number* Card Expires (MMYY) Date *Three-digit (Visa, MasterCard, or Discover) or four-digit (American Express) security code American LegalNet, Inc. www.FormsWorkFlow.com