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Foreign Certificate Of Withdrawal Upon Conversion To A Nonfiling Entity - The Commonwealth Of Massachusetts

The Commonwealth of Massachusetts

FPC

William Francis Galvin

Secretary of the Commonwealth

One Ashburton Place, Boston, Massachusetts 02108-1512

Foreign Certiﬁ cate of Withdrawal

FORM MUST BE TYPED

Upon Conversion to a Nonﬁ ling Entity

(General Laws Chapter 156D, Section 15.22; 950 CMR 113.52)

(1) Exact name of corporation: ___________________________________________________________________________

(2) Jurisdiction of incorporation: __________________________________________________________________________

(3) Type of other entity into which it has converted: ___________________________________________________________

(4) Jurisdiction upon conversion: _________________________________________________________________________

(5) If the foreign business corporation has been converted into a foreign other entity:

(a) Th e corporation revokes the authority of its registered agent to accept service on its behalf.

(b) Th e Secretary of the Commonwealth is hereby appointed 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 the commonwealth.

(6) Th e corporation’s mailing address to which the Division may mail a copy of any process served on it:

________________________________________________________________________________________________

(number, street, city or town, state, zip code)

(7) Th e corporation shall notify the Division of any future changes to the above mailing address by ﬁ ling a certiﬁ cate of amendment.

(8) Th e corporation hereby certiﬁ es that all taxes known to be due the commonwealth have been paid or provided for.

(9) Th is certiﬁ cate is eﬀ ective at the time and on the date approved by the Division, unless a later eﬀ ective date not more than 90

days from the date of ﬁ ling is speciﬁ ed: __________________________________________________________________

Signed by: ___________________________________________________________________________________________ ,

(signature of authorized individual)

® Chairman of the board of directors,

® President,

® Other oﬃ cer,

® Court-appointed ﬁ duciary,

on this _________________________ day of_________________________________________

day of_________________________________________

day of

, _____________________ .

P.C.

c156ds1522950c11352 01/13/05

Foreign Certificate Of Withdrawal Upon Conversion To A Nonfiling Entity - The Commonwealth Of Massachusetts