I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct and that
I have remitted the required fee.
________________________________________________
_______________________
Signature of authorized person representing the acquired entity
Date
________________________________________________
________________________________
Name of signer, printed or typed
Title
Instructions:
i
1. Submit this form with the $75 filing fee. Make checks payable to the Kansas Secretary of State.
There is a $25 service fee for all checks returned by your fi nancial institution.
NOTICE:
Page 2 of 2
K.S.A . 17-78-301 - K.S.A. 17-78-306
Rev. 7/01/10 nr