Form Nfp 113.45 - Application For Withdrawal And Final Report

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NFP 113.45
FORM
(rev. Dec. 2003)
APPLICATION FOR WITHDRAWAL
AND FINAL REPORT
General Not For Profit Corporation Act
Foreign Corporations
Secretary of State
Department of Business Services
501 S. Second St., 350
Springfield, IL 62756
217-782-6961
Remit payment in the form of a
check or money order payable
to Secretary of State.
Filing Fee: $5
____________________________________ File #______________________________
Approved: ___________
———— Submit in duplicate ———— Type or Print clearly in black ink ———— Do not write above this line ————
1. Corporate Name: ________________________________________________________________________________
2. State or Country of Incorporation: ___________________________________________________________________
3. The Corporation surrenders its authority to conduct affairs in Illinois.
4. The Corporation revokes the authority of its Registered Agent in Illinois to accept services of process in any suit, action
or proceeding based upon any cause of action arising in this State during the time this Corporation was licensed to con-
duct affairs in this State may hereafter be made on such Corporation by service thereof upon the Secretary of State.
5. Post Office Address to which the Secretary of State may mail a copy of any process served upon it against the
Corporation: ____________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
6. The undersigned Corporation has caused this statement to be signed by a duly authorized officer who affirms, under
penalties of perjury, that the facts stated herein are true and correct.
All signatures must be in BLACK INK.
Dated _______________________________ , _____
________________________________________________
Month Day
Year
Exact Name of Corporation
______________________________________
Any Authorized Officer’s Signature
______________________________________
Name and Title (type or print)
Printed by authority of the State of Illinois. January 2015 - 1 - C 161.11

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