STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Office of the Secretary of State Corporations Division 148 W. River Street Providence, Rhode Island 02904-2615 (401) 222-3040 INSTRUCTIONS FOR FILING APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF A FOREIGN NON-PROFIT CORPORATION Section 7-6-83 of the General Laws of Rhode Island, 1956, as amended The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant statutory provision. This form and the information provided are not substitutes for the advice and services of an attorney and/or tax specialist. 1. A foreign non-profit corporation authorized to conduct affairs in this state may withdraw from this state upon procuring from the secretary of state a certificate of withdrawal. In order to procure a certificate of withdrawal from the state of Rhode Island, a foreign non-profit corporation shall make application therefor by filing an Application for Certificate of Withdrawal (Form No. 254) with the Office of the Secretary of State, Corporations Division, at the above address. When the application is properly completed, signed and submitted with the correct filing fee, a Certificate of Withdrawal shall be issued. 2. The Application for Certificate of Withdrawal must be accompanied by a filing fee of $10.00, and payment should be made payable to the Rhode Island Secretary of State. 3. At the time of filing the Application, the corporation must be in good standing and current with the filing of its annual reports and the maintenance of its registered agent and its registered office in this state. 4. The Application must be signed by the corporation’s president or vice president and secretary or assistant secretary. A signature must appear on each line even if the same person holds both offices. If you have any questions, please call us at (401) 222-3040, Monday through Friday, between 8:30 a.m. and 4:30 p.m. Instructions/Form 254 Revised: 12/05 American LegalNet, Inc. www.USCourtForms.com Filing Fee: $10.00 ID Number: ____________ STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Office of the Secretary of State Corporations Division 148 W. River Street Providence, Rhode Island 02904-2615 NON-PROFIT CORPORATION _____________ APPLICATION FOR CERTIFICATE OF WITHDRAWAL Pursuant to the provisions of Section 7-6-83 of the General Laws of Rhode Island, 1956, as amended, the undersigned foreign non-profit corporation hereby applies for a Certificate of Withdrawal from the state of Rhode Island, and for that purpose submits the following statement: 1. The name of the corporation is 2. It is incorporated under the laws of 3. It is not conducting affairs in the state of Rhode Island. 4. It hereby surrenders its authority to conduct affairs in the state of Rhode Island. 5. It revokes the authority of its registered agent in Rhode Island to accept service of process and consents that service of process in any action, suit, or proceeding based upon any cause of action arising in Rhode Island during the time the corporation was authorized to conduct affairs in Rhode Island may hereafter be made on the corporation by service thereof on the Secretary of State of the State of Rhode Island. 6. The post office address to which the secretary of state may mail a copy of any process against the corporation that may be served on him or her is: Under penalty of perjury, we declare and affirm that we have examined this Application for Certificate of Withdrawal, and that all statements contained herein are true and correct. Date: Print Exact Name of Corporation Making Application By _________________________________________________ President or Vice President (check one) AND By _________________________________________________ Secretary or Form No. 254 Revised: 12/05 Assistant Secretary (check one) American LegalNet, Inc. www.USCourtForms.com