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State Form 4160 (R11 / 1-09) Approved by State Board of Accounts, 2007 Indiana Code 23-1-46-3 (for profit corporation) Indiana Code 23-17-23-3 (for not-for-profit corporation)

APPLICATION FOR REINSTATEMENT

TODD ROKITA SECRETARY OF STATE Mail to the following address: BUSINESS SERVICES DIVISION 302 W. Washington St., Room E018 Indianapolis, IN 46204 Telephone: (317) 232-6576 Make check or money order payable to Secretary of State

NOTE:

THIS APPLICATION CANNOT BE ACCEPTED WITHOUT A CERTIFICATE OF CLEARANCE FOR REINSTATEMENT FROM THE INDIANA DEPARTMENT OF REVENUE. Application must include the following: 1. Certificate of Clearance: Issued by the Indiana Department of Revenue 2. Corporate Reports and Fees: Please call our information line at 317-232-6576 to learn what reports are due or log onto the web site at www.sos.in.gov. a. Up to and including 1995, Annual Reports filed every year. Annual Report fee $15.00 b. Beginning with 1996, Biennial Reports filed every two (2) years. Biennial Report fee $30.00 Corporations incorporated in an even year, file every even year. Corporations incorporated in an odd year, file every odd year. c. Nonprofit corporations file Annual Reports every year. Nonprofit corporation Report fee $10.00 3. Reinstatement filing fee: $30.00 plus business entity report fee.

INSTRUCTIONS:

SECTION I - CORPORATE INFORMATION
Name of corporation Date of incorporation (month, day, year)

Effective date of administrative dissolution (month, day, year)

SECTION II - AFFIDAVIT OF CORPORATE OFFICER OF DIRECTOR

The undersigned, being at least one of the principal officers or a director of the above-named corporation deposes and says: A. that the grounds for dissolution did not exist or have been eliminated, and; B. that the Corporation's name satisfies the requirements of Indiana Code 23-1-23-1, or Indiana Code 23-17-5-1.

IN WITNESS WHEREOF, the undersigned being the ______________________________________________ of
Title

said corporation executes this application and verifies, subject to penalties of perjury, that the statements contained herein are true, this __________ day of ______________________________________, 20 _________.

Signature

Printed name