Assumed Business Name - Cancellation Secretary of State - Corporation Division - 255 Capitol St. NE, Suite 151 - Salem, OR 97310-1327 sos.oregon.gov/business - Phone: (503) 986-2200 Print Form REGISTRY NUMBER: Reset Form In accordance with Oregon Revised Statute 192.410-192.490, the information on this application is public record. We must release this information to all parties upon request and it will be posted on our website. For office use only Please Type or Print Legibly in Black Ink. Attach Additional Sheet if Necessary. 1. ASSUMED BUSINESS NAME: 2. PRINCIPAL PLACE OF BUSINESS: (Street Address, City, State, Zip) 3. SIGNATURE(S): (Authorized Representative or All Registrants must sign.) I declare as an authorized signer, under penalty of perjury, that this document does not fraudulently conceal, obscure, alter, or otherwise misrepresent the identity of any person including officers, directors, employees, members, managers or agents. This filing has been examined by me and is, to the best of my knowledge and belief, true, correct and complete. Making false statements in this document is against the law and may be penalized by fines, imprisonment, or both. CONTACT NAME: (To resolve questions with this filing) PHONE NUMBER: (Include area code) FEES Required Processing Fee $50 Processing Fees are nonrefundable. Please make check payable to "Corporation Division". Free copies are available at sos.oregon.gov/business using the Business Name Search program. Assumed Business Name Cancellation (11/17) American LegalNet, Inc. www.FormsWorkFlow.com