Foreign Application For Transfer Of Authority

F The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth FPC One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Foreign Application For FORM MUST BE TYPED Transfer of Authority (General Laws, Chapter 156D, Section 15.23; 950 CMR 113.53) (1) Exact name of corporation: ___________________________________________________________________________ (2) Type of other entity into which the corporation has conv ________________________________________________erted: (3) Jurisdiction upon transfer of authority: __________________________________________________________________ (4) Attach an additional sheet(s) containing all other information required in a ? ling under the laws of the commonwealth by an other entity of the type the corporation has become seeking authority to transact business in the commonwealth. (5) h is certi? cate is 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 of ? ling is speci? ed: __________________________________________________________________ Attach certi? cate of legal existence or a certi? cate of good standing issued by an o cer or agency properly authorized in the jurisdiction of organization. If the certi? cate is in a foreign language, a translation thereof under oath of the translator shall be attached. 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.comc156ds1523950c11353 01/13/05<<<<<<<<<********>>>>>>>>>>>>> 2 COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 Foreign Application For Transfer of Authority (General Laws, Chapter 156D, Section 15.23; 950 CMR 113.53) I hereby certify that upon examination of this foreign application for transfer of authority, duly submitted 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 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 $250.00 Examiner Name approval TO BE FILLED IN BY CORPORATION Contact Information: C ___________________________________________________________ M ___________________________________________________________ # A.R. ___________________________________________________________ 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