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Form 635_0128 - Application For Certificate Of Withdrawal (Nonprofit Corporation) - 2001

CHESTER J. CULVER

Application for

Certificate of Withdrawal

Secretary of State

(Nonprofit Corporation)

State of Iowa

TO THE SECRETARY OF STATE OF THE STATE OF IOWA:

Pursuant to provisions of the Iowa Nonprofit Corporation Act, the undersigned applies for a certificate of

withdrawal from Iowa, and states:

1. The name of the corporation is _____________________________________________________________

and the name the corporation uses in Iowa if different than its real name is:

_____________________________________________________________________________________

2. The corporation is incorporated under the laws of the state [or foreign country] of ______________________

3. The corporation is not transacting business in Iowa and surrenders its authority to transact business in Iowa.

4. The corporation revokes the authority of its registered agent to accept service on its behalf and appoints the

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 transact business in Iowa.

5. The mailing address to which the secretary of state may mail a copy of any process served on the

secretary of state is:

Name ________________________________________________________________________________

Address _______________________________________________________________________________

City, State, ZIP _________________________________________________________________________

The corporation will notify the secretary of state in the future of any change in this mailing address.

6. I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true

and correct.

Date

Signature (President or Vice-President) ______________________________________________________

Signature (Secretary or Assistant Secretary) __________________________________________________

NOTES:

1. The filing fee is $5.00. Make checks payable to Secretary of State.

2. The information you provide will be open to public inspection under Iowa Code section 22.11.

Secretary of State

Lucas Building, 1st Floor

Des Moines, Iowa 50319

Phone: 515/281-5204

635_0128

rev 06/01

Form 635_0128 - Application For Certificate Of Withdrawal (Nonprofit Corporation) - 2001