Free 39034.FH11 - Indiana

APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY
State Form 39034 (R8 / 3-07) Corporate Form No. 115 Approved by the State Board of Accounts, 2007 Indiana Code 23-1-49-4; 23-17-26-4

TODD ROKITA SECRETARY OF STATE Mail to the following address: BUSINESS SERVICES DIVISION 302 W. Washington St., Room E018 Indianapolis, IN 46204 T elephone: (317) 232-6576

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NOTE: An Original Certificate of Existence duly authenticated by the proper authority from the corporations domiciliary state within the last sixty (60) days must be submitted with this application. INSTRUCTIONS: 1. Use 8 1/2" x 11" white paper for attachments. 2. Present original and one copy to address in upper right corner of this form. 3. Please TYPE or PRINT. 4. Please visit our office on the web at www.sos.in.gov.

Filing Fee: $ 30.00 Make check or money order payable to Secretary of State

APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY OF
Name of Corporation

A FOREIGN CORPORATION ADMITTED TO TRANSACT BUSINESS IN INDIANA
The undersigned officers of ___________________________________________________________________________________ (hereinafter referred to as the "Corporation"), which exists pursuant to the provisions of the laws of ___________________________ as amended, desire to obtain an Amended Certificate of Authority.

1. The above Corporation received a Certificate of Authority to transact business in the State of Indiana on the _______________ ARTICLE II - REPRESENTATION BY THE WITHDRAWING CORPORATION day of ___________________________________________ , 20 _________ .

2. The Corporation desires to change its corporate name in Indiana as follows: _____________________________________________________________________________________________________

3. The Corporation has changed the period of its duration from _____________________________________________________ to ___________________________________________________.

4. The Corporation has changed the state or country of its incorporation from _________________________________________ to ______________________________________.

5. The Corporation has converted the entity type to a ___________________________________________________________.

In Witness Whereof, the undersigned, being the ________________________________________________________ of said
Title

Corporation executes this Application for Amended Certificate of Authority and verifies, subject to penalties of perjury, that the statements contained herein are true, this ____________ day of ____________________________________ , 20 ________.
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