Free Corp. 49 - Missouri

State of Missouri
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Robin Carnahan, Secretary of State
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1. The Corporation's name is and it is organized and existing under the laws of

2. The corporation is not transacting business in this state, and it surrenders its authority to transact business in the State of Missouri. 3. The corporation revokes the authority of its registered agent to accept service on its behalf and appoints the Missouri Secretary of State as its agent for service of process in any proceeding based on a cause of action arising during the time it was authorized to do business in the State of Missouri. 4. The mailing address to which the Secretary of State may mail a copy of any service of process is:

5. The corporation will notify the Secretary of State of any future changes of mailing address. 6. The effective date of this document is the date it is filed by the Secretary of State of Missouri unless a future date is otherwise indicated:

In Affirmation thereof, the facts stated above are true and correct: (The undersigned understands that false statements made in this filing are subject to the penalties provided under Section 575.040, RSMo)

Authorized Signature of Officer or Chairman of the Board

Name and address to return filed document: Name: Address: City, State, and Zip Code:
Corp. 49 (11/2008)

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Corporations Division PO Box 778 / 600 W. Main St., Rm. 322 Jefferson City, MO 65102

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Application for Certificate of Withdrawal of a Foreign Nonprofit Corporation
(Submit with filing fee of $10.00)

Missouri Charter #:

Address

City, State, Zip

(Date may not be more than 90 days after the filing date in this Office)

Printed Name

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