Form N-04 - Articles Of Merger Nonprofit Corporation/hospital Author

State of North Carolina

Department of the Secretary of State

ARTICLES OF MERGER

NONPROFIT CORPORATION/HOSPITAL AUTHORITY

Pursuant to

55A-11-10 of the General Statutes of North Carolina, the undersigned corporation/Hospital Authority does hereby

submit the following Articles of Merger as the surviving corporation in a merger between a domestic Hospital Authority and

another Hospital Authority or a charitable or religious nonprofit corporation.

1. The name of the surviving corporation/Hospital Authority is ___________________________________________,

a corporation/Hospital Authority organized under the laws of ________________*, North Carolina; the name of the

merged Hospital Authority is:

_______________________________________________________, a Hospital Authority organized under the laws of

_______________,* North Carolina. (*provide the name of the city and county that the Hospital Authority is formed in)

2. Attached is a copy of the Plan of Merger that was duly approved in the manner prescribed by law for each of

the corporations/Hospital Authorities participating in the merger.

** (Complete item 3 if the surviving entity is a charitable or religious corporation, complete item 4 if the surviving entity is a

county Hospital Authority)

3. With respect to the surviving charitable or religious corporation (check either a, b, and/or c, as applicable):

a.___ Member approval was not required for the merger, and the plan of merger was approved by a sufficient vote of the

board of directors.

b.___ Member approval was required for the merger, and the plan of merger was approved by the members as required by

Chapter 55A of the North Carolina General Statutes.

c.___ Approval of the plan of merger by some person or persons other than the members or the board was required pursuant

to N.C.G.S. Section 55A-11-03(a)(3), and such approval was obtained.

A plan of merger was approved by the city and by a majority of the members of the board of commissioner of the city

Hospital Authority.

4. ____ A plan of merger was approved by the city and the county, and a majority of each of the boards of commissioners of

the Hospital Authorities.

5. These articles will be effective upon filing, unless a delayed date and/or time is specified: ____________________________

This is the _____day of ________________, 20___.

_______________________________________________

Name of Corporation

_______________________________________________

Signature

_______________________________________________

Type or Print Name and Title

Notes:

1. Filing fee is $25. This document and one exact or conformed copy of these articles must be filed with the Secretary of State.

2. Certificate(s) of Merger must be registered pursuant to the requirements of N.C.G.S. Section 47-18.1.

(Revised January 2000)

(Form N-04)

CORPORATIONS DIVISION

P.O. BOX 29622

RALEIGH, NC 27626-0622

Form N-04 - Articles Of Merger Nonprofit Corporation/hospital Author - 2000