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NONPROFIT CORPORATION STATE OF MAINE

TERMINATION OF STATEMENT OF INTENTION TO CARRY ON ACTIVITIES UNDER AN ASSUMED OR FICTITIOUS NAME

_____________________ Deputy Secretary of State

A True Copy When Attested By Signature

______________________________________
(Real Name of Corporation)

_____________________ Deputy Secretary of State

Pursuant to 13-B MRSA §308-A.8, the undersigned corporation executes and delivers the following Termination of Statement of Intention to Carry on Activities Under an Assumed or Fictitious Name: FIRST: SECOND: The corporation no longer intends to carry on activities under an assumed or fictitious name. The corporation intends to terminate the assumed or fictitious name of ______________________________________________________________________________________________. THIRD: The address of the registered office of the corporation in the State of Maine is ________________________________ ______________________________________________________________________________________________.
(street, city, state and zip code)

DATED _________________________

*By ___________________________________________________
(signature)

__________________________________________________
(type or print name and capacity)

*By __________________________________________________
(signature)

__________________________________________________
(type or print name and capacity)

*This document MUST be signed by any duly authorized officer. (13-B MRSA §104.1.B) Please remit your payment made payable to the Maine Secretary of State.

SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE, 101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101 FORM NO. MNPCA-5A Rev. 9/16/2005 TEL. (207) 624-7752