Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605)773-4845 APPLICATION FOR REINSTATEMENT DOMESTIC COOPERATIVE Please Type or Print Clearly in Ink Please submit one Original and one Photocopy FILING FEE: $125 payable to SECRETARY OF STATE Telephone # ____________________ FAX # _______________________ 1. The name of the cooperative is ____________________________________________________________________ ______________________________________________________________________________________________ Note: This must be the exact cooperative name. 2. The effective date of its administrative dissolution ______________________________________________________ Any cooperative administratively dissolved may apply to the secretary of state for reinstatement within 2 years after the effective date of dissolution. 3. State that the ground or grounds for dissolution either did not exist, or have been eliminated by filing all required reports and paying all fees and penalties. 4. Attached hereto are ALL delinquent annual reports and filing fees. Dated ____________________________ ______________________________________________ (Signature of an authorized officer) ______________________________________________ (Printed Name) ______________________________________________ (Title) STATE OF _____________________________ COUNTY OF ___________________________ On this the ___________ day of _________________________, 20 ____ before me personally appeared ____________________________________________________________ known to me or satisfactorily proven to be the person who is described in, and who executed the within instrument and acknowledged to me that she/he/they executed the same. _________________________________ My Commission Expires ______________________________________________ Notary Public Notarial Seal domesticcooperativereinstartment July 2008 American LegalNet, Inc. www.FormsWorkflow.com