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STATE OF MONTANA

This is the minimum information required.

(This space for use by the Secretary of State only)

CERTIFICATE of WITHDRAWAL

of FOREIGN NONPROFIT CORPORATION

APPLICATION

35-2-831, MCA

LINDA McCULLOCH

MAIL:

Secretary of State

P.O. Box 202801

Helena, MT 59620-2801

PHONE:

(406) 444-3665

FAX:

(406) 444-3976

WEB SITE:

sos.mt.gov

Required Filing Fee: $15.00

 24 Hour Priority Handling check box & Add $20.00

1 Hour Expedite Handling check box & Add $100.00

For the purpose of withdrawing from the State of Montana as a nonprofit corporation the undersigned submits the following

statements of fact to the Secretary of State:

1. The exact name of the corporation: _________________________________________________________________________

2. It is incorporated under the laws of: _________________________________________________________________________

3. It is not transacting business in Montana and it hereby surrenders its authority to transact business and conduct affairs in

Montana.

4. It revokes the authority of its registered agent in Montana to accept service of process on its behalf and appoints the secretary

of state as its agent for service of process in any proceeding based on a cause of action arising during the time it was authorized

to do business in this state

5. Provide a business mailing address to which the Secretary of State may mail a copy of any process against the corporation

served on him:

Business mailing address: __________________________________________________________________________________

City/town: ____________________________________________ State: ____________________ Zip Code: _______________

6. It will notify the Secretary of State should any other changes be made in its mailing address.

7. The reason for filing this withdrawal (this information is optional):_________________________________________________

________________________________________________________________________________________________________

8. The execution of any document required to be filed with the Secretary of State constitutes an affirmation, under penalties of

false swearing, by each person executing the document that the facts stated therein are true

(35-1-428,

MCA).

________________________________________________________

__________________________________________

Signature of officer or chairman of board

Title

_______________________________________________________

__________________________________________

Printed name of individual signing

Date

Daytime Contact: Phone _____________________ Email _________________________________________________________

sos.mt.gov/Business/Forms

66-Foreign_Nonprofit_Corporation_Certificate_of_Withdrawal.doc

Revised: 11/14/2011

Form 35-2-831, Mca - Certificate Of Withdrawal Of Foreign Nonprofit Corporation Application - Montana

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