State of Wisconsin DEPARTMENT OF FINANCIAL INSTITUTIONS Division of Corporate & Consumer Services FILING FEE $30.00 Please check box to request Optional Expedited Service + $25.00 DFI/CORP/124(04/18) 1 FORM 12 4 FOREIGN NON - STOCK, NOT FOR PROFIT CORPORATION WITHDRAWAL APPLICATION Sec. 181.1520, Wis. Stats. 1. , a foreign nonstock corporation (Corporation Name) organized under the laws of and holding a certificate of authority to (State/Country) transact business in Wisconsin, hereby surrenders that authority, applies for a Certificate of Withdrawal, and states: 2.The corporation is not transacting business in Wisconsin. 3.The authority of its registered agent to accept service of process on its behalf is hereby revoked. 4.The corporation hereby consents to service of process under sec. 181.1510(3) and (4) in any civil,criminal, administrative or investigatory proceeding based on a cause of action arising during the time it was authorized to transact business in Wisconsin. its mostrecent annual report, is: Street Address PO Box City State/Province Country Zip/Postal Code 6.The corporation agrees to notify the Department of Financial Institutions of any future change in themailing address of its principal office. 7.Executed on (Date) (Signature) Title: President Secretary or other officer title (Printed name) This document was drafted by (Name the individual who drafted the document) American LegalNet, Inc. www.FormsWorkFlow.com DFI/CORP/124(04/18) 2 FOREIGN NONSTOCK CORPORATION - WITHDRAWAL APPLICATION Please provide an email or postal mailing address for the filed copy of the document. INSTRUCTIONS (Ref. sec. 181.1520, Wis. Stats. for document content) Please use BLACK ink. Submit one original to State of WI-Dept. of Financial Institutions, Box 93348, Milwaukee WI, 53293-0348, together with a check for the filing fee, payable to the department. Filing fee is non-refundable. (If sent by Express or Priority U.S. mail, please visit www.wdfi.org/contactus/ for current physical address). This document can be made available in alternate formats upon request to qualifying individuals with disabilities. The original must include an original manual signature. Upon filing, the information in this document becomes public and might be used for purposes other than those for which it was originally furnished. If you have any questions, please contact the Division of Corporate & Consumer Services at 608-261-7577. Hearing-impaired may call 711 for TTY. NOTICE: This form may be used to accomplish a filing required or permitted by statute to be made with the department. Information requested may be used for secondary purposes. This document can be made available in alternate formats upon request to qualifying individuals with disabilities. This application for withdrawal is mandatory for use by a foreign non-stock corporation, including a non-profit corporation. Foreign business corporations apply on Form 24. 1. Enter the name of the corporation and the state in which it is incorporated. If the corporation is licensed in this state under a fictitious name, provide the fictitious name as well. 2, 3 & 4. These statements are required under sec. 181.1520 Wis. Stats. most recent annual report. 6. Sec. 181.1520 requires a commitment by the corporation to notify the department in the future of any change in the mailing address of its principal office. 7. The application is to be executed by an officer of the corporation. Print or type the name and title of the officer signing the application and the date it was signed. American LegalNet, Inc. www.FormsWorkFlow.com