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FORM NFP 113.45(rev. Dec. 2003)
APPLICATION FOR WITHDRAWAL
AND FINAL REPORT
General Not For Profit Corporation Act
Foreign Corporations
Secretary of State
Department of Business Services
5 01 S. Second St., 350
Springfield, 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: $5              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. The Corporation surrenders its authority to conduct affairs in Illinois.

4. The Corporation revokes the authority of its Registered Agent in Illinois to accept services 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 con-
duct affairs in this State may hereafter be made on such Corporation by service thereof upon the Secretary of State.

5. Post Office Address to which the Secretary of State may mail a copy of any process served upon it against the
Corporation:____________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

6. 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 inBLACK INK.

Dated _______________________________ ,  _____    ________________________________________________ 
                                 Month   Day                                  Year                                               Exact Name of Corporation

     ______________________________________
                          Any Authorized Officer’s Signature

     ______________________________________
                             Name and Title (type or print)

                               Printed by authority of the State of Illinois. January 2015 - 1 - C 161.11