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Sec. 180.1520 Wis. Stats.

State of Wisconsin DEPARTMENT OF FINANCIAL INSTITUTIONS Division of Corporate & Consumer Services

FOREIGN BUSINESS CORPORATION ­ WITHDRAWAL AND FINAL REPORT APPLICATION
(Note: This application consists of four sections, the statement in item 1, the final report, item 2, the fee computation in item 3, and the execution section, item 4, all of which must be completed.)

1. APPLICATION FOR WITHDRAWAL
, a foreign corporation
(Corporation Name)

organized under the laws of
(State/Country)

and holding a certificate of authority to

transact business in Wisconsin, hereby surrenders that authority, applies for a Certificate of Withdrawal, and states: A. The corporation is not transacting business in Wisconsin. B. The authority of its registered agent to accept service of process on its behalf is hereby revoked. C. The corporation hereby consents to service of process under sec. 180.1510(3) and (4) in any civil, criminal, administrative or investigatory proceeding based on a cause of action arising during the time it was authorized to transact business in Wisconsin. D. The mailing address of the corporation's principal office, if different from that shown on its most recent annual report, is:
Street Address City State/Province Country PO Box Zip/Postal Code

E. The corporation agrees to notify the Department of Financial Institutions of any future change in the mailing address of its principal office.

__________________________________________________________________________________ FILING FEE - $40.00, or more. DFI/CORP/24(R09/05)
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2. FINAL REPORT Compute the highest proportion of capital the corporation had represented in Wisconsin since the filing of the last Wisconsin Foreign Corporation Annual Report. If no annual report has been filed, calculate from the date of the application for certificate of authority. (NOTE: Start by completing items A(1) thru A(7). Continue, and in sequence, first complete item B and next item C, as each or both may be necessary, and post the results to item A and complete the computations in item A. Corporations having both Par Value and No Par Value shares issued will utilize both item B and item C.
A.(1) (2) (3) (4) (5) (6) Gross Business Plus Total Assets Total of lines (1) and (2) Wisconsin business Plus Wisconsin Assets Total of lines (4) and (5) $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ ___________%

(7) Divide line (6) by line (3) and enter percentage (8) Value of Issued Shares of PAR VALUE stock from item B (3) $_____________ (9) Value of Issued Shares of NO PAR VALUE stock from line C (7) $_____________ (10) Total of lines (8) and (9) (11) Multiply line (10) by line (7) and enter product here and on line 3 A, in section 3 $___________

$_____________

B. PAR VALUE STOCK (Use this section to compute valuation of Par Value stock only) (1) Value of issued shares of Par Value stock, computed at PAR $_____________ (2) Paid-in capital, in excess of Par, applicable to issued shares of Par Value stock $_____________ (3) Total of lines (1) and (2). Also enter $_____________ this sum on line A (8) above C. NO PAR VALUE STOCK (Use this section to compute valuation of No Par Value stock only) (1) Total asset $_____________ (2) Deduct liabilities other than capital and Surplus $_____________ (3) Total of line (1) minus line (2) $_____________ (4) Deduct amount of line A (8) above $_____________ (5) Remainder of line (3) minus line (4) $_____________ (6) Compute value of issued shares of NO PAR VALUE stock at $10.00 per share $_____________ (7) Enter the GREATER of line (5) or line (6) here. Also Enter this sum on line A (9) above. $_____________

DFI/CORP/24(R09/05)
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3. COMPUTATION OF FILING FEE
A. The corporation's highest capital representation in Wisconsin for the period of the final report (from line 2 A. (11), Section 2) was $ ______________ B. Deduct capital representation on which fee has been paid (Note: All foreign corporations will have paid fee on not less than $25,000 of capital representation. If this figure is unknown, contact the Department of Financial Institutions for this information. 608-261-7577) $ ______________ C. Deduct line 3 B. from line 3 A. $ ______________

D. If the sum on line 3 C. is positive, compute a fee of $3.00 for each $1,000 (or any part there of ) of such sum and enter the product here. If the sum in item 3 C. is negative, enter "zero." E. ADD the base filing fee of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F. The sum of line 3 D. and Line 3 E. is the FILING FEE

$ ______________ $

40.00

$ ______________

4. Executed on
(Date) Title: President Secretary (Printed name) (Signature)

or other officer title

INSTRUCTIONS (Ref. sec. 180.1520, Wis. Stats. for document content) Submit one original and one exact copy along with the required filing fees from section 3F above to the address listed below. Make checks payable to the "Department of Financial Institutions". Filing fee is non-refundable. Sign the document manually or otherwise as allowed under Sec. 180.0103(16) Wis. Stats. Physical Address for Express Mail: Mailing Address: Phone: 608-261-7577 Department of Financial Institutions Department of Financial Institutions FAX: 608-267-6813 Division of Corporate & Consumer Services Division of Corporate & Consumer rd TTY: 608-266-8818 345 W. Washington Ave ­ 3 Fl. Services P O Box 7846 Madison WI 53703 Madison WI 53707-7846 NOTICE: This form may be used to accomplish a filing required or permitted by statute to be made with the department. Information requested may be used for secondary purposes. This document can be made available in alternate formats upon request to qualifying individuals with disabilities.

DFI/CORP/24(R09/05)
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FOREIGN BUSINESS CORPORATION WITHDRAWAL AND FINAL REPORT APPLICATION









Enter your return address within the brackets above. Phone number during the day: ( ) ______ -____________

INSTRUCTIONS CONTINUED (Ref. sec. 180.1520, Wis. Stats. for document content)

1. Enter the name of the corporation and the state in which it is incorporated. If the corporation is licensed in this state under a fictitious name, provide the fictitious name as well. A, B & C. These statements are required by sec. 180.1520(2)(b) and (c). D. If the address of the corporation's principal office has changed from that indicated on its most recent annual report, provide the new address in item D. 2. Provide complete information to all items in section 2. Post the figure from line 2 A. (11) to line A. in section 3. 3. The filing fee is the sum of the base filing fee of $40.00, plus any additional amount that may be due on an increase in capital representation during the final report period on which fee has not been paid. The fee computed at the rate of $3.00 per $1,000 (or any part thereof) of the increase. (Note: The Corporation has, as a result of obtaining a certificate of authority, paid on at least $25,000 of capital representation. It may have paid more at its initial qualification, or may have paid on increases in capital representation disclosed on its Foreign Corporation Annual Reports filed over the term of its qualification. If this figure is unknown to the preparer, call the department and ask for the amount of capital representation on which the corporation has paid fee. 608-261-7577.) 4. The application is to be executed by an officer of the corporation. Print or type the name and title of the officer signing the application and the date it was signed.

DFI/CORP/24I(R09/05)
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