Application For Certificate Of Withdrawal Form - Secretary Of State

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SECRETARY OF STATE

Clear Form

STATE CAPITOL

500 E. CAPITOL AVE.

APPLICATION FOR

PIERRE, S.D. 57501

Information

CERTIFICATE OF WITHDRAWAL

(605)773-4845

FAX (605)773-4550

Pursuant to the provisions of the South Dakota Business Corporation Act, the undersigned corporation hereby applies for a Certificate of Withdrawal from

your State, and for that purpose submits the following statement:

1. The name and address of the corporation is _________________________________________________________________________________________

______________________________________________________________________________________________________________________________

2. It is incorporated under the laws of the state of ______________________________________________________________________________________

3. That this corporation is not doing or engaging in any business in this state, and hereby surrenders its authority to transact business in South Dakota.

4. It revokes the authority of its registered agent in your State to accept service of process, and consents that service of process in any action, suit or proceeding

based upon any cause of action arising in your State during the time the corporation was authorized to transact business in your State may thereafter be made

on the corporation by service thereof on the Secretary of State of your State.

5. The post-office address to which the Secretary of State may mail a copy of any process against the corporation that may be served on him is ____________

______________________________________________________________________________________________________________________________

6. The aggregate number of shares which it has authority to issue, itemized by classes, par value of shares, shares without par value, and series, if any, within a

class, as of this date is:

Number

Par value per share or statement that

of shares

Class

Series

shares are without par value

7. The aggregate number of its issued shares, itemized by classes, par value of shares, shares without par value, and series, if any, within a class, as of this date

is:

Number

Par value per share or statement that

of shares

Class

Series

shares are without par value

(8) The amount of its stated capital as of this date is $ __________________________________________________________________________________

To be signed in the presence of a notary public by either the chairman of the board of directors, or by the president or any other officer.

Dated _________________

_______________________________________________________________

(Signature)