STATE OF SOUTH CAROLINA 
                                            SECRETARY OF STATE 

                        APPLICATION BY A FOREIGN NONPROFIT CORPORATION 
         FOR A CERTIFICATE OF WITHDRAWAL FROM THE STATE OF SOUTH CAROLINA 

Pursuant to Section 33-31-1520 of the 1976 S.C. Code of Laws, as amended, the undersigned nonprofit corporation
hereby applies for a certificate of withdrawal authorizing it to withdraw from the State of South Carolina and to 
surrender its authority to transact business in the State of South Carolina.  The undersigned hereby appoints the 
Secretary of State as agent for service of process and commits to notify the Secretary of State of any change in mailing 
address. 

1. The name of the foreign nonprofit corporation as filed in South Carolina:

2. The corporation is incorporated under the laws of: ___________________________    (State or Country)
3. The corporation received a certificate of authorization to transact business in South Carolina dated: __________

4. The corporation is no longer transacting business in South Carolina.

5. The corporation hereby surrenders its authority to transact business in the State of South Carolina.

6. The corporation revokes the authority of its registered agent in South Carolina to accept service of process on its
behalf and appoints the Secretary of State as its agent for service of process in any action, suit, or proceeding based
upon any cause of action arising during the time it was authorized to do business in this State.

7.The address to which the Secretary of State may mail a copy of any process against the corporation that may be
served on him is:

_____________________________________________________________________________________________ 
(Street Address) 

_____________________________________________________________________________________________ 
(City, State, Zip Code) 

8. Unless a delayed date is specified, this application shall be effective upon acceptance for filing by the Secretary of

State [See Section 33-31-123(b) of the 1976 S.C. Code of Laws, as amended]                 : __________

Date: __________ 

Name of Corporation: 

Signature: ____________________________________________________________________________________ 

Name: _______________________________________________________________________________________ 

Officer Title: ___________________________________________________________________________________

                                                              Form Revised by South Carolina Secretary of State, April 2018
                                                                                                                   F0116 

                                            FILING INSTRUCTIONS 

1.Include a self-addressed stamped envelope to have a filed copy returned to you by mail.
2. If space on this form is insufficient, please attach additional sheets containing a reference to the appropriate 
paragraph in this form.

3. This application must be accompanied by the filing fee of $10.00, payable to the Secretary of State. 

Return to:  Secretary of State 
            Attn:  Corporate Filings 
            1205 Pendleton Street, Suite 525 
            Columbia, SC 29201 

                                                            Form Revised by South Carolina Secretary of State, April 201 8
                                                                                                                    F0116