SPECIAL NOTE: Utah law requires corporations seeking withdrawal to submit a Tax Clearance Certificate with the Application for Withdrawal. Please inquire with the Utah State Tax Commission at 210 N 1950 W Salt Lake City, Utah 84134. Phone: (801) 297-2200 or Toll Free: (800) 662-4335. Pursuant to the provisions of Utah Law, the undersigned corporation hereby submits this Application for Withdraw from the State of Utah, and for that purpose submits the following statement: First: Corporation Name is Second: It is incorporated under the laws of the state of Third: It is no longer transacting business in Utah. Fourth: It hereby surrenders its authority to transact business in Utah. Fifth: Service of process in any action, suit or proceeding based upon any cause of action arising in Utah during the time the corporation was authorized to transact business in Utah may thereafter be made on the corporation by service thereof on the (check one): [ ] Registered Agent of Record (For Profit Corporations Only) Name Address City State Zip (Utah Street Address Required, PO Boxes can be listed after the street address) [ ] The Principal Office Address City State Zip (Street Address Required, PO Boxes can be listed after the street address) Under penalties of perjury, I declare that this Application for Withdrawal, and the accompanying Tax Clearance Certificate, has been examined by me and is, to the best of my knowledge and belief, true, correct and complete. Dated this day of , 20 By: Title: If the filer requests a copy of the Application for Withdrawal an additional exact copy of the filed document along with a return-addressed envelope with adequate first-class postage must also be submitted. Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity. State of Utah DEPARTMENT OF COMMERCE Division of Corporations & Commercial CodeApplication for Withdrawal Entity Number: [ ] Profit Corporation [ ] Non-Profit Corporation American LegalNet, Inc. www.FormsWorkFlow.com