Articles Of Charter Surrender Upon Foreign Non-Profit Conversion

D The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth PC One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Articles of Charter Surrender FORM MUST BE TYPED Upon Foreign Non-pro? t Conversion (General Laws Chapter 156D, Section 9.33; 950 CMR 113.27) (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 the conversion of the corporation to a foreign non-pro? t corpora- tion. (4) h e conversion is permitted by the laws of the foreign jurisdiction. (5) Corporations new name: _____________________________________________________________________________ New jurisdiction of incorporation: _____________________________________________________________________ (6) h e foreign non-pro? t 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. (7) 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. (8) 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__________________________________________________________________________________, _____________________. American LegalNet, Inc.P.C. www.USCourtForms.com c156ds933950c11327 01/13/05<<<<<<<<<********>>>>>>>>>>>>> 2 COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 Articles of Charter Surrender Upon Foreign Non-pro? t Conversion (General Laws Chapter 156D, Section 9.33; 950 CMR 113.27) I hereby certify that upon examination of these articles charter of surrender, duly sub- mitted to me, it appears that the provisions of the General Laws relative thereto have been complied with, and I hereby approve said articles; and the ? ling fee in the amount of $______ having been paid, said articles are deemed to have been ? led with me this _____________day 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 Filing fee: Minimum $250 Examiner TO BE FILLED IN BY CORPORATION # A.R. 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