Application For Reinstatement Following Administrative Dissolution

D The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth PC One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED FORM MUST BE TYPED Application For Reinstatement Following Administrative Dissolution (General Laws Chapter 156D, Section 14.22; 950 CMR 113.47) (1) Exact name of corporation: ___________________________________________________________________________ (2) Registered o * ce address: _____________________________________________________________________________ (number, street, city or town, state, zip code) Name of the registered agent at registered o * ce: ___________________________________________________________ (3) E ) ective date of the corporations administrative dissolution: __________________________________________________ (month, day, year) (4) h e grounds for administrative dissolution: (check appropriate box) did not exist. have been eliminated. (5) h e corporations name satis? es the requirements of G.L. Chapter 156D, Section 4.01. (6) h e reinstatement of the corporation shall be e ) ective at the time and on the date approved by the Division, unless a later ef- fective date not more than 90 days from the date and time of ? ling is speci? ed: ____________________________________ (7) Attach a certi? cate from the Commonwealth of Massachusetts Department of Revenue reciting that all corporate excise taxes and any related penalties have been paid or a request to the Department of Revenue for this certi? cate. (8) h e Division shall: (check appropriate box) reinstate the corporation without limitation.* limit reinstatement to a speci? ed period of time not to exceed one year. * e corporation must ? le annual reports for the previous ten (10) ? scal years, if not previously ? led. P.C. c156ds142295011347 01/13/05 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Signed by: ___________________________________________________________________________________________, (signature of authorized individual) Chairman of the board of directors, President, Other o * cer, Court-appointed ? duciary, on this _________________________day of_________________________________________, _____________________. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 Application for Reinstatement Following Administrative Dissolution (General Laws Chapter 156D, Section 14.22; 950 CMR 113.47) I hereby certify that upon examination of this application for reinstatement, duly submit- ted to me, it appears that the provisions of the General Laws relative thereto have been complied with, and I hereby approve said application; and the ?ling fee in the amount of $______ having been paid, said application is deemed to have been ?led with me this _____________day of ______________20_______ at _______a.m./p.m. time E ) ective date: ____________________________________________________ (must be within 90 days of date submitted) WILLIAM FRANCIS GALVIN Secretary of the Commonwealth Examiner Name approval Filing fee: $100 #A.R. TO BE FILLED IN BY CORPORATION Contact Information: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Telephone: ___________________________________________________ Email: ______________________________________________________ Upon ? ling, a copy of this ? ling will be available at www.sec.state.ma.us/cor. If the document is rejected, a copy of the rejection sheet and rejected document will be available in the rejected queue. American LegalNet, Inc. www.USCourtForms.com