1. Converting/Domesticating Entity Name: ______________________________________________________________
2. Date of Filing of the Statement of Conversion/Domestication
: _____________________________________________
3. The Statement of Conversion/Domestication has been abandoned in accordance to Section 204/304 of the Entity
Omnibus Act.
4. The undersigned Entity has caused this statement to be signed by a duly authorized signer who affirms, under
penalties of perjury, that the facts stated herein are true and correct. All signatures must be in BLACK INK.
Dated _______________________________ , ________ ______________________________________
Month & Day Year Exact Name of Entity
_________________________________________
Any Authorized Signer’s Signature
_________________________________________
Name and Title (type or print)
Printed by authority of the State of Illinois. June 2018 — 1 — C 350.1
EOA 204/304
Illinois Secretary of State
Department of Business Services
STATEMENT OF ABANDONMENT
OF CONVERSION/DOMESTICATION
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-6961
www.cyberdriveillinois.com
Remit payment in the form of a
check or money order payable
to Secretary of State.
Filing Fee: $100 ________________________________________________________________ Approved: ______________
———— Submit in duplicate ———— Type or print clearly in black ink ———— Do not write above this line ————
_______________________
Entity File Number
Please circle the applicable transaction type in items 1-3.
