Form 603Last Revised: 06/2019 Toll Free: 877.767.3453 | Central Ohio: 614.466.3910 OhioSoS.gov | business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Filing Form Cover LetterPlease return the approval certificate to: Address: City: ZIP Code: Phone Number: E-mail Address: Check here if you would like to receive important notices via e-mail from the Ohio Secretary of State's office regarding Business Services. Check here if you would like to be signed up for our Filing Notification System for the business entity being created or updated by filing this form. This is a free service provided to notify you via e-mail when any document is filed on your business record. Please make checks or money orders payable to: "Ohio Secretary of State" Type of Service Being Requested: (PLEASE CHECK ONE BOX BELOW) Regular Service: Only the filing fee listed on page one of the form is required and the filing will be processed in approximately 3-7 business days. The processing time may vary based on the volume of filings received by our office. Expedite Service 1: By including an Expedite fee of $100.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 2 business days after it is received by our office. Expedite Service 2: By including an Expedite fee of $200.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 1 business day after it is received by our office. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Expedite Service 3: By including an Expedite fee of $300.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 4 hours after it is received by our office, if received by 1:00 p.m. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Preclearance Filing: A filing form, to be submitted at a later date for processing, may be submitted to be examined for the purpose of advising as to the acceptability of the proposed filing for a fee of $50.00. The Preclearance will be complete within 1-2 business days. Name (Individual or Business Name): To the Attention of (if necessary): StatePage 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form 603Last Revised: 06/2019Toll Free: 877.767.3453 Central Ohio: 614.466.3910 OhioSoS.gov business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Mail this form to one of the following: Regular Filing (non expedite) P.O. Box 1329 Columbus, OH 43216 Expedite Filing (Two business day processing time. Requires an additional $100.00) P.O. Box 1390 Columbus, OH 43216 Certificate of Dissolution (Cooperative Association) Filing Fee: $50 (150-DISS) Form Must Be Typed The association named below has adopted a resolution of dissolution. The resolution of dissolution was adopted by the: Location of Principal Office Name and address of the Statutory Agent Name of association Charter Number Incorporators Directors Members City County State Complete the following information.Form 603 Prescribed by: For screen readers, follow instructions located at this path. Name of Statutory Agent Mailing Address City State ZIP CodePage 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form 603Last Revised: 06/2019 If the resolution of dissolution was adopted by the incorporators, or a majority of the incorporators, before subscriptions for membership and any other stock or other ownership interest have been received, then please provide the following: Names and addresses of the Incorporators If the resolution was adopted by directors, then please complete the following: The basis for such adoption is: Name Address Name Address Name Address The association has been adjudged bankrupt or has made a general assignment for the benefit or creditors. By leave of the court, a receiver has been appointed in a general creditors' suit or in any suit in which the affairs of the association are to be wound up. Substantially all of the assets have been sold at judicial sale or otherwise. The Articles of Incorporation have been cancelled for failure to file annual franchise or excise tax returns or for failure to pay franchise or excise taxes and the association has not been reinstated or does not desire to be reinstated. The period of existence of the association specified in its articles has expired. (Individual Agent's Signature / Signature on Behalf of Business Serving as Agent)Statutory Agent Signaturehereby acknowledges and accepts the appointment of statutory agent for said association. (Name of Association)Statutory agent for, named herein as theThe Undersigned, (Name of Statutory Agent)Acceptance of AppointmentPlease complete this section if the corporation is appointing a new agent.Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form 603Last Revised: 06/2019 Name Address Name Address Name Address Name Address Name Address Name AddressPlease provide the following if the resolution of dissolution was adopted by directors or members. Names and addresses of the directorsNames and addresses of the officers Print Name By (if applicable) Signature Print Name By (if applicable) SignatureBy signing and submitting this form to the Ohio Secretary of State, the undersigned hereby certifies that he or she has the requisite authority to execute this document.Required Must be signed by not less than a majority of the incorporators, if dissolved by incorporators. Must be signed by any authorized representative if dissolved by directors or members. If authorized representative is an individual,then they must sign in the "signature"box and print their name in the "Print Name" box. If authorized representative is a business entity, not an individual, then please print the business name in the "signature" box, an authorized representative of the business entity must sign in the "By" box and print their name in the"Print Name" box. Page 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form 603Last Revised: 06/2019 Name of Association Signature Title Name Mailing Address City State ZIP Code Notary Public Date Notified (MM/DD/YYYY) Acknowledged before me and subscribed in my presence on this date (MM/DD/YYYY)AFFIDAVITComplete the information in this section.In lieu of dissolution releases from various governmental authorities for a Cooperative Association, (ORC section 1729.55(H)).The undersigned, being first duly sworn, declares that on the dates indicated below, each of the named state governmental agencies was advised IN WRITING of the scheduled date of filing of the Certificate of Dissolution and was advised IN WRITING of the acknowledgement by the corporation of the applicability of the provisions of section 1729.55 of the ORC.AgencyOhio Department of Taxation Dissolution Section 4485 Northland Ridge Blvd. Columbus, Ohio 43229AgencyOhio Job & Family Services Status and Liability Section Data Correspondence Control Fax: 614-752-4811 Phone: 614-466-2319TreasurerNote: This affidavit must be signed by a person executing the certificate of dissolution or by an officer of the corporation.SealOvernight Address: P.O. Box 182413 Columbus, OH 43218-2413Regular Address: P.O. Box 182413 Columbus, OH 43218-2413The treasurer of any county named below: Date Commission Expires (MM/DD/YYYY) Date Notified (MM/DD/YYYY) Date Notified (MM/DD/YYYY)* Only required for domestic for-profit corporations Date Notified (MM/DD/YYYY)Ohio Bureau of Workers'Compensation 30 W. Spring Street Columbus, Ohio 43215AgencyPage 5 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form 603Last Revised: 06/2019Complete the information in this section.AFFIDAVIT OF PERSONAL PROPERTYPursuant to ORC 1729.55(H)(1) State of County of Name of Officer Title of Officer Name of Association A. Has no personal property in any county in the state of Ohio B. Has personal property in the following county(ies) C. Association is of the type required to pay personal property taxes to state authorities only County County County Date Commission Expires (MM/DD/YYYY) Notary Public Acknowledged before