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FORM BCA 13.45        (rev. Dec.            2003)
APPLICATION FOR   WITHDRAWAL
AND FINAL REPORT
Business Corporation Act
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350 
Springfield, IL  62756
217-782-6961
www.ilsos.gov

Remit payment in the form of a 
check or money order payable 
to Secretary of State.

___________________________________ File #______________________________    Filing Fee: $25                                                                         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. Post  Office Address  to  which  the  Secretary  of  State  may  mail  a  copy  of  any  process  served  upon  it  against  the
cor poration:
______________________________________________________________________________________________

______________________________________________________________________________________________

4. No portion of the Corporation’s issued shares at this time is represented by business transacted or property located in
Illinois.

5. The Corporation surrenders its authority to transact business in Illinois.

6. The  Corporation  revokes  the  authority  of  its  registered  agent  in  Illinois  to  accept  service  of  process,  and  hereby
consents that service 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  transact  business  in  this  State  may  hereafter  be  made  on  such
corporation by service thereof upon the Secretary of State.

                                                 (COMPLETE ONLY WHEN APPLICABLE)

7. a. List all issuances of shares not previously reported to the Secretary of State (including shares issued for cash or
     other property, share dividends, share splits, share exchanges pursuant to Section 11.10, and shares to effect an
     exchange or reclassification of issued shares), and give the value of the entire consideration received therefor, less
     expenses; list any amounts added or transferredSeeto paid-inNotecapital,1 on                                                        without the issuance of shares. (
     reverse.)

          Date of Issuance                                                                                                                           Number of        Entire Consideration
       ____________      or Contribution       _____________               Class              ______________          Par Value                  ______________         Shares Issued      ______________          Received

                                                                                                                                                                           $_____________
                                                                                                                                                                           $_____________
                                                                                                                                                        TOTAL       $_____________

                                                 (COMPLETE BOTH SIDES OF DOCUMENT)

                                            Printed by authority of the State of Illinois. January 2015 - 1 - C 164.14



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    b. List all cancellations of shares not previously reported to the Secretary of State and give the cost.

           Date of Cancellation                                      Class                                          Number of Shares Cancelled                                      Cost    ______________                  _______________                     ____________________                  ______________

                                                                                                                                                                   $_____________
                                                                                                                                                                   $_____________
                                                                                                                         TOTAL       $_____________

8. Issued shares at date of execution:

                      Class                                                 Series                                                         Par Value                                          Number of Shares______________________________________________________________________________________________

    ______________________________________________________________________________________________
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________

9. Paid-in capital at date of execution:
                                                                                                                         Paid-in Capital   $____________________
(“Paid-in Capital” replaces the terms “Stated Capital” and “Paid-in Surplus” and is equal to the total of these accounts.)

10. 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)

                                                                NOTE
1. In the event of an increase in paid-in capital, all applicable franchise taxes, penalties and interest must be paid before
this document can be accepted for filing.






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