AMENDED APPLICATION FOR CERTIFICATE OF AUTHORITY TO

CSCL/CD-565 (09/21)

DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

CORPORATIONS, SECURITIES

COMMERCIAL LICENSING BUREAU

Date Received

(FOR BUREAU USE ONLY)

This document is effective on the date filed,unless a

subsequent effective date within 90

days after received

date is stated in the document.

Name

EFFECTIVE DATE:

Address

City State Zip code

Document will be returned to the name and address you enter above

AMENDED APPLICATION FOR CERTIFICATE OF AUTHORITY

TO CONDUCT AFFAIRS IN MICHIGAN

For

use by Foreign Nonprofit Corporations

(Please read information and instructions on the last page)

Pursuant to the provisions of Act 162, Public Acts of 1982, the undersigned corporation executes the following

Amended Application:

The name of the corporation is:

If the name in Item 1 was not available for use in Michigan, the assumed name adopted when obtaining the

Certificate of Authority is:

The identification number assigned by the Bureau is:

It is incorporated under the laws of

The corporation was authorized to conduct affairs in Michigan on

The period of its duration (corporation term) is

If the name of the corporation has changed, its new name is:

and the

the effective date of the name change was the day of

name change was made in compliance with the laws of the jurisdiction of its incorporation.

Complete this Item only if the new name in Item 7 is not available for use in Michigan. The assumed name of

the

corporation to be used in all its dealings with the Bureau and in the transaction of its business in Michigan is:

If the assumed name in Item 2 has changed, the new name is:

AC1

10.

The name of the resident agent at the registered office is:

The address of its registered office in Michigan is:

(Zip Code)

The mailing address of the registered office in Michigan, if different than above, is:

(Zip Code)

The resident agent is an agent of the corporation upon whom process against the corporation may be served.

11.

The address of the main business or headquarters office of the corporation is:

(Street Address)

(City)

(State) (Zip Code)

The mailing address if different than above is:

(Street Address or P.O. Box) (City)

(State)

(Zip Code)

12.

If the affairs the foreign corporation proposes to conduct in this State is to be enlarged, limited, or

otherwise changed, the

specific

affairs which the corporation is to conduct in Michigan is as follows:

The corporation is authorized to conduct such affairs in the jurisdiction of its incorporation.

Signed this

day of

(Signature of Authorized Officer or Agent)

(Type or Print Name)

Michigan

(City)

(Street Address)

(City)

(Street Address or P.O. Box)

CSCL/CD-565 (Rev. 09/21)

Preparer's name:

(

INFORMATION AND INSTRUCTIONS

This amended application must be used to amend the Application for Certificate of Authority to Conduct Affairs in

Michigan. A document required or permitted to be filed under the act cannot be filed unless it contains the minimum

infomation required by the act. This is a legal document and agency staff cannot provide legal advice.

Submit one original of this document. Upon filing, the document will be added to the records of the Corporations,

Securities

Commercial Licensing Bureau. The original will be returned to your registered office address, unless

you enter a different address on the front of this document.

Since this document will be maintained on electronic format, it is important that the filing be legible. Documents with

poor black and white contrast, or otherwise illegible, will be rejected.

This document is to be used pursuant to section 1021 of the Act by foreign nonprofit corporations having a certif icate

of authority to conduct affairs in this State where the information contained in its original or last amended application

has changed. This amended application must be filed no later than 30 days after the time the change becomes

effective in the jur isdiction of its incorporation.

Item 12- This item should state only the specific affairs to be conducted in Michigan. An all purpose activities statement

is not permitted. Foreign corporations can only conduct affairs in this State that a domestic corporation formed under the

Nonprofit Corporation Act can lawfully transact.

The document is effective on the date endorsed "filed" by the Bureau. A later effective date, no more than 90 days

after the date of delivery may be stated.

This amended application must be signed by an authorized officer or agent of the corporation.

FEES: Make remittance payable to the State of Michigan. Include corporation name and identification number on

check or money order.

NONREFUNDABLE FEE.............................................................................................................................................$10.00

To submit by mail: To submit in person:

Department of Licensing and Regulatory Affairs

Corporations, Securities & Commercial Licensing Bureau

Corporations Division

P.O. Box 30054

Lansing, Ml 48909

2407 N Grand River Ave

Lansing, Ml 48906

Telephone : (517) 241-6470

Fees may be paid by VISA, MasterCard, American Express,

or Discover when delivered in person to our office.

Documents that are endorsed filed are available at www.michigan.gov/corpentitysearch. If the submitted document is not

fileable, the notice of refusal to file and document will be available at the Rejected Filings Search website at

www.michigan.gov/corprejectedsearch.

LARA is an equal opportunity employer/program.

Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

Business Telephone Number:

)