Foreign Nonprofit Corporation This Box For Office Use Only Page 1 of 1 See attached detailed instructions □ No Fee for Standard Service □ Expedited Service $50.00 UBI Number: CERTIFICATE OF WITHDRAWAL Chapter 24.03 RCW A Washington State Department of Revenue Clearance Certificate Must Be Attached SECTION 1 NAME OF CORPORATION: (as currently recorded with the Office of the Secretary of State) NAME USED IN WASHINGTON STATE: (If different than above) SECTION 2 STATEMENTS BY THE FOREIGN NON PROFIT CORPORATION: (please check ALL of the following) □ □ □ This corporation is not conducting affairs in Washington State This corporation surrenders the authority to conduct affairs in Washington State The corporation hereby revokes the authority of its registered agent in Washington 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 Washington during the time the corporation was authorized to conduct affairs in Washington may thereafter be made on the corporation by service thereof on the Secretary of State of Washington. SECTION 3 ADDRESS WHERE SERVICE OF PROCESS MAY BE FORWARDED: (REQUIRED) Address: _______________________________City___________________State Zip Code_______ SECTION 4 SIGNATURE: (see instructions page) This document is hereby executed under penalties of perjury, and is, to the best of my knowledge, true and correct. X __________________________________________________________________________ Signature Printed Name and Title of Officer Date Phone *A Washington State Department of Revenue Clearance Certificate Must Be Attached* Foreign Nonprofit Corporation - Withdrawal Washington Secretary of State Revised 07/10 American LegalNet, Inc. www.FormsWorkFlow.com Instructions – Foreign Nonprofit Corporation Certificate of Withdrawal Please complete all sections of the Certificate of Withdrawal. USE DARK INK ONLY. For an electronic, fillable version of this form, please visit our website at www.sos.wa.gov/corps Section 1 Provide the nonprofit corporation name as currently recorded with the Office of the Secretary of State. Section 2 In order to process the Certificate of Withdrawal you must review and check each box in section 2. Section 3 A Foreign Nonprofit Corporation must complete this section with an address where service of process may be forwarded. Section 4 The signer must be an officer (President, Vice President, Secretary or Treasurer) or an official with authorized capacity on behalf of the corporation. Additional Information: A Washington State Department of Revenue Clearance Certificate Must Be Attached. This completed certificate must be obtained from the Department of Revenue prior to filing for withdrawal. Not providing all required information may result in a rejection of the document and could create a delay in processing. The request for a revenue clearance certificate can be found at: http://www.sos.wa.gov/corps/forms/appwthdrwlordissolcorpguaranty_e.pdf Fees: There is no fee for a standard filing of Certificate of Withdrawal. If expedited service is requested, include a $50.00 check and write “EXPEDITE” on the outside of the envelope. Make the checks or money orders payable to “Secretary of State”. (ALL fees are non-refundable) Mail completed forms and payment to: Secretary of State Corporation Division 801 Capitol Way S PO Box 40234 Olympia WA 98504-0234 If you have questions, need assistance, or would like to provide feedback please visit the Corporations Division website at www.sos.wa.gov/corps or call 360-725-0377. Foreign Nonprofit Corporation - Withdrawal Washington Secretary of State Print Form Revised 07/10 American LegalNet, Inc. www.FormsWorkFlow.com