Form Sfn 13101 - Certificate Of Withdrawal Foreign Corporation Application - North Dakota Secretary Of State

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FOR OFFICE USE ONLY

CERTIFICATE OF WITHDRAWAL

System ID Number

FOREIGN CORPORATION APPLICATION

Work Order Number

SECRETARY OF STATE

SFN 13101 (5-2012)

Filed

1. FILING FEE $20.00

SEE INSTRUCTIONS FOR FEES, FILING AND MAILING INFORMATION.

This form is prescribed for use by a foreign business corporation, a foreign professional corporation, or a foreign nonprofit corporation.

The following statements are hereby submitted for Certificate of Withdrawal from the State of North Dakota. The Secretary of State may request any

additional information necessary or appropriate to determine and assess any unpaid fees payable by the foreign corporation.

For reference, see North Dakota Century Code, Section 10-19.1-140 or 10-33-133.

TYPE OR PRINT LEGIBLY

2. Name of Corporation

3. Federal ID Number

4. State or Country Where Incorporated

5. Address to Which a Person May Mail a Copy of Any Process Against the Corporation: (Street/RR, PO Box, City, State, ZIP+4)

6. "The following is hereby affirmed:

The corporation is not transacting business or conducting activities in North Dakota and surrenders its authority to do so.

The corporation revokes the authority of its registered agent in North Dakota to accept service of process. The corporation consents to service of

process on the corporation by service upon the North Dakota Secretary of State in any action, suit, or proceeding based upon any cause of action arising

in North Dakota during the time the corporation was authorized to transact business or conduct activities.

The corporation authorizes the Secretary of State to correct numbers 2 and 4 if not reflected as registered.

The undersigned, a person authorized by the corporation to sign this application, knows the contents of the application, and believes the statements

made to be true. I understand that if I make a false statement in this document, I may be subject to criminal penalties."

Signature:

Date

Daytime Telephone Number and Extension,

7. Name of Person to Contact About This Application

E-mail Address

if any: