Articles Of Charter Surrender Upon Conversion To A Foreign Other Entity

D The Commonwealth of Massachusetts William Francis Galvin PC Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Articles of Charter Surrender FORM MUST BE TYPED Upon Conversion to a Foreign Other Entity (General Laws Chapter 156D, Section 9.54; 950 CMR 113.32) (1) Exact name of corporation: ___________________________________________________________________________ (2) Registered o ce address: _____________________________________________________________________________ (number, street, city or town, state, zip code) (3) h e articles of charter surrender are ? led in connection with a conversion to a foreign other entity. (4) Type of entity: _____________________________________________________________________________________ (5) Name of new entity: ________________________________________________________________________________ New jurisdiction of incorporation: ______________________________________________________________________ (6) h e corporation hereby appoints the Secretary of the Commonwealth as its agent for service of process in any proceeding to enforce the rights of shareholders who exercise appraisal rights in connection with the conversion. (7) h e conversion was duly approved by the shareholders, and where required, by each separate voting group as provided by G.L. Chapter 156D and the articles of organization. (8) Street address of its executive o ce immediately after the conversion if the surviving entity will be a non-? ling entity: ________________________________________________________________________________________________ (number, street, city or town, state, zip code) (9) h e charter surrender shall be e ) ective at the time and on the date approved by the Division, unless a later e ) ective date not more than 90 days from the date and time of ? ling is speci? _______________________________________________ ed: Signed by: ___________________________________________________________________________________________, (signature of authorized individual) Chairman of the board of directors, President, Other o cer, Court-appointed ? duciary, on this _________________________day ofday ofday of__________________________________________________________________________________, _____________________.P.C. American LegalNet, Inc.c156ds954950c11332 01/13/05 www.USCourtForms.com <<<<<<<<<********>>>>>>>>>>>>> 2 COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 Articles of Charter Surrender Upon Conversion to a Foreign Other Entity (General Laws Chapter 156D, Section 9.54; 950 CMR 113.32) I hereby certify that upon examination of this certi? cate of charter surrender,it ap- pears that the provisions of the General Laws relative thereto have been complied with, and the ? ling fee in the amount of $______ having been paid, said certi? cate is deemed to have been ? led with me thisday ofday ofday 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 Filing fee: Minimum $250 #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