Application For Amendment Or Withdrawal (Foreign Nonprofit) {61}

Application for Amendment/Withdrawal - Foreign Nonprofit Secretary of State - Corporation Division - 255 Capitol St. NE, Suite 151 - Salem, OR 97310-1327 sos.oregon.gov/business - Phone: (503) 986-2200 Check the appropriate box below: AMENDMENT TO APPLICATION FOR AUTHORITY (Complete only 1, 2, 8) WITHDRAWAL OF AUTHORITY TO TRANSACT (Complete only 3, 4, 5, 6, 7, 8) REGISTRY NUMBER: In accordance with Oregon Revised Statute 192.410-192.490, the information on this application is public record. We must release this information to all parties upon request and it will be posted on our website. For office use only Please Type or Print Legibly in Black Ink. Attach Additional Sheet if Necessary. AMENDMENT TO APPLICATION ONLY 1) ENTITY NAME: 2) AMENDMENT: (The amendment is as follows.) WITHDRAWAL OF AUTHORITY TO TRANSACT BUSINESS ONLY 3) NAME: 4) STATE OR COUNTRY OF INCORPORATION: 5) THIS CORPORATION IS NOT TRANSACTING BUSINESS IN OREGON, AND SURRENDERS ITS AUTHORITY TO TRANSACT BUSINESS IN OREGON. 6) THIS CORPORATION REVOKES THE AUTHORITY OF ITS REGISTERED AGENT TO ACCEPT SERVICE 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 TRANSACT BUSINESS IN OREGON. 7) MAILING ADDRESS: (The address to which the person initiating any proceeding may mail to this Corporation a copy of any process served on the Secretary of State. The Corporation will notify the Corporation Division, Business Registry of any change in this mailing address for a period of five years from the date of this withdrawal.) 8) EXECUTION: (Must be signed by at least one officer or director.) I declare as an authorized signer, under penalty of perjury, that this document does not fraudulently conceal, obscure, alter, or otherwise misrepresent the identity of any person including officers, directors, employees, members, managers or agents. This filing has been examined by me and is, to the best of my knowledge and belief, true, correct and complete. Making false statements in this document is against the law and may be penalized by fines, imprisonment, or both. Signature: Printed Name: Title: CONTACT NAME: (To resolve questions with this filing.) FEES Required Processing Fee $50 PHONE NUMBER: (Include area code.) Processing Fees are nonrefundable. Please make check payable to Corporation Division. Free copies are available at sos.oregon.gov/business using the Business Name Search program. 61 - Application for Amendment/Withdrawal - Foreign Nonprofit (11/17) American LegalNet, Inc. www.FormsWorkFlow.com