Free APPLICATION FOR WITHDRAWAL AND FINAL REPORT - Illinois

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FORM BCA 13.45 (rev. Dec. 2003) APPLICATION FOR WITHDRAWAL AND FINAL REPORT Business Corporation Act Secretary of State Department of Business Services Springfield, IL 62756 217-782-6961 www.cyberdriveillinois.com Remit payment in the form of a check or money order payable to Secretary of State.

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____________________________________ File #______________________________

Filing Fee: $25

Approved: ___________

-------- Submit in duplicate -------- Type or Print clearly in black ink -------- Do not write above this line --------

1. Corporate Name: ________________________________________________________________________________ 2. State or Country of Incorporation: ___________________________________________________________________ 3. Post Office Address to which the Secretary of State may mail a copy of any process served upon it against the corporation: ______________________________________________________________________________________________ ______________________________________________________________________________________________ 4. No portion of the Corporation's issued shares at this time is represented by business transacted or property located in Illinois. 5. The Corporation surrenders its authority to transact business in Illinois. 6. The Corporation revokes the authority of its registered agent in Illinois to accept service of process, and hereby consents that service of process in any suit, action or proceeding based upon any cause of action arising in this State during the time this Corporation was licensed to transact business in this State may hereafter be made on such corporation by service thereof upon the Secretary of State. (COMPLETE ONLY WHEN APPLICABLE) 7. a. List all issuances of shares not previously reported to the Secretary of State (including shares issued for cash or other property, share dividends, share splits, share exchanges pursuant to Section 11.10, and shares to effect an exchange or reclassification of issued shares), and give the value of the entire consideration received therefor, less expenses; list any amounts added or transferred to paid-in capital, without the issuance of shares. (See Note 1 on reverse.)
Date of Issuance or Contribution ____________ Class _____________ Par Value ______________ Number of Shares Issued ______________ Entire Consideration Received ______________

$_____________ $_____________ TOTAL $_____________

(COMPLETE BOTH SIDES OF DOCUMENT)

Printed by authority of the State of Illinois. June 2006 - 5M - C 164.13

b. List all cancellations of shares not previously reported to the Secretary of State and give the cost.
Date of Cancellation ______________ Class _______________ Number of Shares Cancelled ____________________ Cost ______________

$_____________ $_____________ TOTAL 8. Issued shares at date of execution:
Class Series Par Value Number of Shares ______________________________________________________________________________________________

$_____________

______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 9. Paid-in capital at date of execution: Paid-in Capital $____________________ ("Paid-in Capital" replaces the terms "Stated Capital" and "Paid-in Surplus" and is equal to the total of these accounts.) 10. The undersigned Corporation has caused this statement to be signed by a duly authorized officer who affirms, under penalties of perjury, that the facts stated herein are true and correct. All signatures must be in BLACK INK. Dated _______________________________ , _____
Month & Day Any Authorized Officer's Signature Year

________________________________________________
Exact Name of Corporation

______________________________________ ______________________________________
Name and Title (type or print)

NOTE 1. In the event of an increase in paid-in capital, all applicable franchise taxes, penalties and interest must be paid before this document can be accepted for filing.

Printed by authority of the State of Illinois. June 2006 - 5M - C 164.13