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F The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
FPC
One Ashburton Place, Boston, Massachusetts 02108-1512
FORM MUST BE TYPED Foreign Certifi cate of Withdrawal FORM MUST BE TYPED
Upon Conversion to a Nonfi ling Entity
(General Laws Chapter 156D, Section 15.22; 950 CMR 113.52)
(1) Exact name of corporation: ___________________________________________________________________________
(2) Jurisdiction of incorporation: __________________________________________________________________________
(3) Type of other entity into which it has converted: ___________________________________________________________
(4) Jurisdiction upon conversion: _________________________________________________________________________
(5) If the foreign business corporation has been converted into a foreign other entity:
(a) Th e corporation revokes the authority of its registered agent to accept service on its behalf.
(b) Th e Secretary of the Commonwealth is hereby appointed as its agent for service of process in any proceeding based on a
cause of action arising during the time it was authorized to transact business in the commonwealth.
(6) Th e corporation’s mailing address to which the Division may mail a copy of any process served on it:
________________________________________________________________________________________________
(number, street, city or town, state, zip code)
(7) Th e corporation shall notify the Division of any future changes to the above mailing address by fi ling a certifi cate of amendment.
(8) Th e corporation hereby certifi es that all taxes known to be due the commonwealth have been paid or provided for.
(9) Th is certifi cate is eff ective at the time and on the date approved by the Division, unless a later eff ective date not more than 90
days from the date of fi ling is specifi ed: __________________________________________________________________
Signed by: ___________________________________________________________________________________________ ,
(signature of authorized individual)
® Chairman of the board of directors,
® President,
® Other offi cer,
® Court-appointed fi duciary,
on this _________________________day of_________________________________________day of_________________________________________day of , _____________________ .
P.C. c156ds1522950c11352 01/13/05
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