Print                       Reset Save

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
S pringfield, IL  62756
217-782-6961
www.cyberdriveillinois.com
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 transferred to paid-in capital, without the issuance of shares. (See Note 1 on
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

    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.