PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Application for Termination of Authority Foreign Corporation (15 Pa.C.S.) Business Corporation (§ 4129) Nonprofit Corporation (§ 6129) Name Document will be returned to the name and address you enter to the left. Address City State Zip Code Fee: $70 In compliance with the requirements of the applicable provisions of 15 Pa.C.S. (relating to corporations and unincorporated associations), the undersigned qualified foreign corporation, desiring to withdraw from doing business in this Commonwealth, hereby states that: 1. The name of the corporation is: 2. The (a) address of this corporation’s current registered office in this Commonwealth or (b) name of its commercial registered office provider and the county of venue is (the Department is hereby authorized to correct the following information to conform to the records of the Department): (a) Number and Street City State Zip (b) Name of Commercial Registered Office Provider c/o: County County 3. The name of the jurisdiction under the laws of which the corporation is incorporated is: 4. The date the corporation received a Certificate of Authority to do business in this Commonwealth: 5. The corporation herewith surrenders its Certificate of Authority to do business in this Commonwealth. American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-4129/6129-2 6. Notice of its intention to withdraw from doing business in this Commonwealth was mailed by certified or registered mail to each municipal corporation in which the registered office or principal place of business of the corporation in this Commonwealth is located and official publication required by 15 Pa.C.S. § 4129(b) or 6129(b) has been effected. 7. Process in any action or proceeding upon any liability incurred before the filing hereof may be sent to the following: Number and Street City State Zip County IN TESTIMONY WHEREOF, the undersigned corporation has caused this Application for Termination of Authority to be signed by a duly authorized officer thereof this day of , . Name of Corporation Signature Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB: 15-4129/6129 Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Web site: www.dos.state.pa.us/corps Instructions for Completion of Form: A. Typewritten is preferred. If not, the form shall be completed in black or blue-black ink in order to permit reproduction. The filing fee for this form is $70 made payable to the Department of State. B. Under 15 Pa.C.S. § 135(c) (relating to addresses) an actual street or rural route box number must be used as an address, and the Department of State is required to refuse to receive or file any document that sets forth only a post office box address. C. The following, in addition to the filing fee, shall accompany this form: (1) Tax clearance certificates from the Department of Revenue and from the Bureau of Employment Security of the Department of Labor and Industry evidencing payment of all taxes and charges payable to the Commonwealth. (2) Any necessary governmental approvals. It is not necessary to submit to the Department the original or an amended certificate of authority for cancellation. D. The corporation is required by 15 Pa.C.S. § 4129(b) or 6129(b) (relating to advertisement) to advertise its intention to withdraw or its withdrawal from doing business in Pennsylvania. Proofs of publication of such advertising should not be submitted to, and will not be received by or fled in the Department, but should be filed with the minutes of the corporation. E. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkFlow.com