Sfn 58782 - Nonprofit Corporation Intent To Dissolve Form

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COMPLETE, PRINT, SIGN, AND FAX OR MAIL

(If paying with credit card complete authorization at bottom of page 2)

FOR OFFICE USE ONLY

NONPROFIT CORPORATION

ID Number

INTENT TO DISSOLVE

WO Number

SECRETARY OF STATE

SFN 58782

(08-2008)

Filed

1. FILING FEE $10.00

For reference, see N.D.C.C., Section 10-33-99

TYPE OR PRINT LEGIBLY

SEE REVERSE SIDE FOR FEES, FILING AND MAILING INSTRUCTIONS.

2. The Name of the Corporation

3. Federal ID Number

4. "Regarding the board of directors' resolution to dissolve:

A. The resolution was adopted at a meeting of the board held on _______________________ (month, day, year)

B. The resolution was adopted at:

______________________________________________________________________________________________________________

(Complete address of place where meeting was held.)

C. The requisite approval of the directors was received."

5. "Regarding the resolution to dissolve by members with voting rights:

"There are no members with voting rights." (If applicable, check the box.)

B. The resolution was adopted by voting members at a meeting held on ________________________ (month, day, year)

C. The resolution was adopted at:

______________________________________________________________________________________________________________

(Complete address of place where meeting was held.)

D. The requisite approval of the members with voting rights was received."

6. "The undersigned, a person authorized by the corporation to sign this Intent to Dissolve, has read the foregoing statements, knows the contents thereof,

and believes the statements made therein to be true. I further authorize the Secretary of State to correct number 2 if not correctly reflected."

Signature

Date

E-mail Address

Daytime Telephone Number

6. Name of person to contact if questions about this document