Free c156ds1522950c11352.indd - Massachusetts

F FPC

The Commonwealth of Massachusetts
William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

FORM MUST BE TYPED

(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) The corporation revokes the authority of its registered agent to accept service on its behalf. (b) The 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) The 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) The corporation shall notify the Division of any future changes to the above mailing address by filing a certificate of amendment. (8) The corporation hereby certifies that all taxes known to be due the commonwealth have been paid or provided for. (9) This certificate is effective at the time and on the date approved by the Division, unless a later effective date not more than 90 days from the date of filing is specified: __________________________________________________________________

Foreign Certificate of Withdrawal Upon Conversion to a Nonfiling Entity

FORM MUST BE TYPED

Signed by: ___________________________________________________________________________________________ , (signature of authorized individual) ® Chairman of the board of directors, ® President, ® Other officer, ® Court-appointed fiduciary,

on this _________________________ day of_________________________________________ , _____________________ . of

P.C.

c156ds1522950c11352 01/13/05

COMMONWEALTH OF MASSACHUSETTS
Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

William Francis Galvin

(General Laws Chapter 156D, Section 15.22; 950 CMR 113.52)
I hereby certify that upon examination of this foreign certificate withdrawal, duly submitted to me, it appears that the provisions of the General Laws relative thereto have been complied with, and I hereby approve said certificate; and the filing fee in the amount of $ ___________________________________________________ having been paid, said certificate is deemed to have been filed with me this _____________ day of _____________, 20______ , at _______a.m./p.m. time Effective date: _____________________________________________________ (must be within 90 days of date submitted)

Foreign Certificate of Withdrawal Upon Conversion to a Nonfiling Entity

WILLIAM FRANCIS GALVIN
Secretary of the Commonwealth Filing fee: $100

Examiner # A.R.

TO BE FILLED IN BY CORPORATION
Contact Information: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Telephone: ___________________________________________________ Email: ______________________________________________________ Upon filing, a copy of this filing will be available at www.sec.state.ma.us/cor. If the document is rejected, a copy of the rejection sheet and rejected document will be available in the rejected queue.