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Sec. 226.14 Wis. Stats.

State of Wisconsin DEPARTMENT OF FINANCIAL INSTITUTIONS Division of Corporate & Consumer Services

WITHDRAWAL AND FINAL REPORT for a COMMON LAW TRUST APPLICATION
1. Name of the Common Law Trust: 2. Organized under the laws of:

The Trust named in 1. above, and holding a certificate of authority to transact business in Wisconsin, hereby surrenders that authority, applies for a certificate of withdrawal from Wisconsin, and states that: A. B. C. D. The Trust is not transacting business in Wisconsin. The authority of its registered agent to accept service of process on its behalf is hereby revoked. The Trust hereby appoints the Department of Financial Institutions as its agent for service in any civil, criminal, administrative or investigatory proceeding based on a cause of action arising while it was authorized to transact business in Wisconsin. The mailing address of the Trust's principal office is:

3.

Street Address: City State Zip Code

E. F.

The Trust agrees to notify the Department of Financial Institutions of any future change in the mailing address of its principal office. Since the Trust last filed an annual report with the Department under sec. 226.14(4), Wis. Stats., it has sold Wisconsin, in the aggregate amount of $ beneficial certificates (shares) in (NOTE: If

certificates (shares) have been sold in Wisconsin, remit with this application $1 for each $1,000 of such sales.)

FILING FEE - $15.00 See instructions on following pages. DFI/CORP724(R02/19/04) Use of this form is voluntary.

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Executed on (Date) (Signature ­ Trustee) (Printed name) This document was drafted by (Name the individual who drafted the document)

INSTRUCTIONS (Ref. sec. 226.14, Wis. Stats. for document content) Submit two signed copies to Department of Financial Institutions, P O Box 7846, Madison WI, 537077846, together with a FILING FEE of $15.00, or more (see instructions, below), payable to the department. Filing fee is non-refundable. (If sent by Express or Priority U.S. mail, address to 345 W. Washington Ave., 3rd Floor, Madison WI, 53703). Both copies must bear original manual signatures. NOTICE: This form may be used to accomplish a filing required or permitted by statute to be made with the department. Information requested may be used for secondary purposes. If you have any questions, please contact the Division of Corporate & Consumer Services at 608-261-7577. Hearingimpaired may call 608-266-8818 for TTY. This document can be made available in alternate formats upon request to qualifying individuals with disabilities. 1. Enter the name of the Common Law Trust. This application may be used to withdraw either a domestic or a foreign common law trust, referred to in some jurisdictions as a "business trust." 2. Enter the jurisdiction under which the Common Law Trust is organized. 3. Enter beneficial certificate and aggregate amount. 4. Signature FILING FEE - $15.00. Remit an additional fee computed at the rate of $1.00 for each $1,000 of beneficial certificates sold or offered for sale in Wisconsin since the Trust last filed an annual report with the department. Your return address and phone number during the day: ( Enter your return address below: ) ______ -

____________

DFI/CORP/724I(R02/19/04)

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