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                         State of New Hampshire 
 
Filing fee: $25.00                                                                                     Form FNP-5 
Use black print or type.                                                                         RSA 292:5b & 
                                                                                              RSA 293-A:15.20 
 
                   APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF A 
                                 FOREIGN NONPROFIT CORPORATION 
 
PURSUANT TO THE PROVISIONS of voluntary corporations and associations and the New Hampshire 
Business Corporation Act, the undersigned corporation hereby applies for a certificate of withdrawal from 
New Hampshire and for that purpose submits the following statement: 
 
FIRST:  The name of the corporation is                                                                               
 
                                                                                                                    . 
 
SECOND:  It is incorporated under the laws of                                        . 
 
THIRD:  It is not transacting business in New Hampshire. 
 
FOURTH:  It hereby surrenders its authority to transact business in New Hampshire. 
 
FIFTH:  It revokes the authority of its registered agent in New Hampshire 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 this state. 
 
SIXTH:  The mailing address to which the Secretary of State may mail a copy of any process against the 
corporation that may be served on him is                                                                             
 
                                                                                                                    . 
 
SEVENTH:  The corporation will notify the Secretary of State in the future of any change in its mailing 
address. 
 
                                                                                                         (Note 1) 
                                                               (Corporate Name) 
 
                                                                                                         (Note 2) 
                                                                      (Signature) 
 
                                                               (Print or type name) 
 
                                                                                                         (Note 2) 
                                                                      (Title) 
 
                                          Date signed:                                                  

Notes:  1.  Exact corporate name of corporation making the statement. 
 
         2.  Signature and title of person signing for the corporation.  Must be signed by chairman of the board of 
         directors, president or another officer; or see RSA 293-A:1.20(f) for alternative signatures. 
 
DISCLAIMER:  All documents filed with the Corporation Division become public records and will be available for 
public inspection in either tangible or electronic form. 
 
Mail fee and DATED AND SIGNED ORIGINAL to:  Corporation Division,rd   Department of State, 107 North Main Street, 
Concord NH 03301-4989.  Physical location:  25 Capitol Street, 3  Floor, Concord, NH 03301. 
 
                                                                                              Form FNP-5  (4/2009)