Closing Form - Oregon Department Of Justice

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1515 SW 5th Ave., Suite 410

For Dissolved

Portland, OR 97201

Oregon Corporations

Oregon Department of Justice

(503) 229-5725

Closing Form

Name of Corporation:

DoJ Registration #:

Value of Total Assets on

(Last) Annual Report: $

Disposition of Assets: List below any individual or organization who received any portion of the corporation’s

assets at the time of dissolution. Attach additional sheets if necessary. If the total value of the assets listed

below is significantly different from the total value of the assets listed on the corporation’s last annual report as

shown above, please attach a written explanation of the difference.

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Name and Address of Individual or Organization

Asset Received

Value of Asset

and, if available, Employer Identification Number

and Tax Exempt Status

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Under penalties of perjury, I declare that the above information is true, complete and correct and that the named

charitable corporation does not solicit contributions or operate as a charitable corporation in Oregon.

____________________________________

_________________

Signature

Date

_________________________________________

______________________________________________

Print Name

Street

_________________________________________

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