CERTIFICATE OF ANNULMENT OF DISSOLUTION AND 

 REINSTATEMENT OF CORPORATE EXISTENCE OF 

                                          (Exact Name of Corporation) 
                             Under Section 1012 of the Not-for-Profit Corporation Law 
 
 FIRST: The name of the corporation is: 
 
 If the name of the corporation has been changed, the name under which it was formed is: 
 
 SECOND: The certificate of incorporation was filed by the Department of State on: 
 (Must include month, day and year) 
 
 THIRD:                  The law under which the corporation was formed is: 
 
 FOURTH: The corporation has failed to deliver to the Department of State a certificate as 
                             required by subdivision one of Section 57 of the Membership Corporations Law. 
 
 FIFTH: The corporation hereby elects to be reinstated and to continue its corporate existence. 
 
 SIXTH: The Corporation is a: [check the appropriate box]       charitable corporation           
                             non-charitable corporation 
 
                                      X   
                                                                                                                    (Signature) 
 
                                                                             (Type or Print Name of Signer) 
 
                                                                                                               (Capacity of Signer) 

 DOS-0639-f (Rev. 02/16)                                                                                                            Page 1 of 2 

         CERTIFICATE OF ANNULMENT OF DISSOLUTION AND 
                         REINSTATEMENT OF CORPORATE EXISTENCE OF 
 
                                                   (Exact Name of Corporation) 
 
                         Under Section 1012 of the Not-for-Profit Corporation Law 
 
                         Filer’s Name:                                                                        

                         Mailing Address: 
 
                         City, State and Zip Code: 
 
 NOTES:  
 1.The certificate must be submitted with          a $30 filing fee. 
 2. This form was prepared by the New York State Department of State. You are not required to use this form. You  
     may draft your own form or use forms available at legal stationery stores.  
 3. The Department of State recommends that all documents be prepared under the guidance of an attorney.  
 
 For Office Use Only 

 DOS-0639-f (Rev. 02/16)                                                                                          Page 2 of 2