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 STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME Section 7-6-11 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. Any non-profit corporation organized under the laws of, or qualified to conduct affairs in this state may abandon a fictitious business name by filing a Statement of Abandonment of Use of Fictitious Business Name (Form No. 627) with the Office of the Secretary of State, Corporations Division, at the above address. 2. When the Statement is properly completed, signed and submitted with the correct filing fee, the Statement of Abandonment of Use of Fictitious Business Name shall be filed. 3. The Statement must be accompanied by a filing fee of $20.00, and payment should be made payable to the Rhode Island Secretary of State. 4. Upon filing the Statement, the entity 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. 5. The Abandonment of Use of Fictitious Business Name shall be executed by an authorized person of the non-profit corporation or by a person with authority to do so under the laws of the state or other jurisdiction of the organization of the non-profit corporation. 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 627 Revised: 12/05 American LegalNet, Inc. www.USCourtForms.com Filing Fee: $20.00 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 ______________ STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME Pursuant to the provisions of Section 7-6-11 of the General Laws of Rhode Island, 1956, as amended, the undersigned non-profit corporation hereby abandons the use of a fictitious business name in the transaction of its affairs in the state of Rhode Island and submits the following: 1. The name of the non-profit corporation is 2. The fictitious business name being abandoned is 3. The date when the original fictitious business name statement being abandoned was filed is 4. The state or other jurisdiction under the laws of which it is incorporated is 5. The date of incorporation is Under penalty of perjury, I declare that the information contained herein is true and correct. Date: Print Name of Applicant Non-Profit Corporation By Signature of Authorized Person Title Form No. 627 Revised: 12/05 American LegalNet, Inc. www.USCourtForms.com