Secretary of State Office         APPLICATION FOR 
500 E Capitol Ave 
                          CERTIFICATE OF WITHDRAWAL 
Pierre, SD 57501 
                          FOREIGN NONPROFIT  ORPORATIONC                        
(605)773-4845
corpinfo@state.sd.us
                                                 FILING FEE: $5 
                                  Make check payable to SECRETARY OF STATE

1. The Name and Business ID of the corporation is:

Name (Note: This must be the exact corporate name as registered.)                  Business ID 

2. The name of the state or other jurisdiction under whose laws it is incorporated:

3. The corporation is no longer doing or engaging in any business in this state and it surrenders its authority to transact
business in South Dakota.

4. The corporation revokes the authority of its registered agent in your State to accept service of process, and consents
that service of process in any action, suit or proceeding based upon any cause of action arising in your State during the
time the corporation was authorized to transact business in your State may thereafter be made on the corporation by 
service thereof on the Secretary of State of your State. 
5. The post-office address to which the Secretary of State may mail a copy of any process against the corporation that
may be served is:

Street Address                                                    City                              State ZIP+4 

Mailing Address if different from street address                  City                              State ZIP+4 

Email Address (Optional) 

The application must be signed by an authorized officer of the corporation. 

No person may execute this report knowing it is false in any material respect.  Any violation may be subject to a civil and/or 
criminal penalty (SDCL 22-39-36). 

Dated 
                                                                  Signature of an authorized person 

Email 
      (Optional)                                                  Printed Name 

                                                                  Title 

                                                                                   nonprofitforeignapplicationwithdrawal Feb 2018