Free APPLICATION FOR WITHDRAWAL AND FINAL REPORT General Not For Profit Corporation Act Foreign Corporations - Illinois

FORM NFP 113.45 (rev. Dec. 2003) APPLICATION FOR WITHDRAWAL AND FINAL REPORT General Not For Profit Corporation Act Foreign Corporations Secretary of State Department of Business Services 501 S. Second St., Rm. 350 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: $5

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. The Corporation surrenders its authority to conduct affairs in Illinois. 4. The Corporation revokes the authority of its Registered Agent in Illinois to accept services 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 conduct affairs in this State may hereafter be made on such Corporation by service thereof upon the Secretary of State. 5. Post Office Address to which the Secretary of State may mail a copy of any process served upon it against the Corporation: ____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 6. 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

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Exact Name of Corporation

______________________________________ ______________________________________
Name and Title (type or print)

Printed by authority of the State of Illinois. March 2007 - 1.5M - C 161.10