PLEASE READ ALL INSTRUCTIONS BEFORE COMPLETING THIS FORM.
FLORIDA DEPARTMENT OF STATE Secretary of State
DIVISION OF CORPORATIONS
1. Corporation Name
2. Principal Office Address - No P.O. Box #
3. Mailing Office Address
Suite, Apt. #, etc.
Suite, Apt. #, etc.
4. Date Incorporated or Qualified
To Do Business in Florida City & State City & State
5. FEI Number
Zip Country Zip Country
Applied For Not Applicable
CERTIFICATE OF STATUS DESIRED
$8.75 Additional Fee required
for a Certificate of Status
7. Name and Address of Current Registered Agent
Street Address (P.O. Box Number is Not Acceptable) Suite, Apt. #, Etc. City State Zip Code
The reinstatement fee is imposed, except in circumstances which the entity did not receive the prior notices. By checking this box, you are certifying the prior notices were not received and requesting the reinstatement fee be waived.
8. I, being appointed the registered agent of the above named corporation, am familiar with and accept the obligations of section 607.0505 or 617.0503, F.S.
Signature of Registered Agent _______________________________________________________________________________________ REGISTERED AGENT MUST SIGN Date ______________________________________
9. Names and Street Addresses of Each Officer and/or Director (Florida nonprofit corporations must list at least 3 directors)
Titles Name of Officers and /or Directors Street Address of Each Officer and /or Director City / State / Zip
10. I certify that I am an officer or director or the receiver or trustee empowered to execute this application as provided for in chapter 607 or 617, F.S. I further certify that when filing
this reinstatement application, the reason for dissolution has been eliminated, the corporate name satisfies the requirements of section 607.0401 or 617.0401, F.S., that all fees owed by the corporation have been paid and the names of individuals listed on this form do not qualify for an exemption contained in Chapter 119, F.S. The information indicated on this application is true and accurate, and my signature shall have the same legal effect as if made under oath.
SIGNATURE AND TYPED OR PRINTED NAME OF SIGNING OFFICER OR DIRECTOR Date Daytime Phone #
ALL APPLICATIONS NOT COMPLETED IN ACCORDANCE WITH THESE INSTRUCTIONS WILL BE RETURNED FOR CORRECTION(S). PLEASE READ ALL INSTRUCTIONS CAREFULLY.
INSTRUCTIONS FOR COMPLETING THE REINSTATEMENT APPLICATION
Block 1 Block 2 Block 3 Block 4 Block 5 Enter the corporation name & document number on file with the Secretary of State in Block 1. The NAME of the corporation can be changed only by filing an amendment. The principal address must be a street address. A Post Office Box can not be used for the principal address. A Post Office Box is acceptable for the mailing address. Type or print the mailing address in Block 3. (NOTE: Annual reports will be mailed to the last known mailing address. Reports are not mailed to the registered office address.) Enter the date of incorporation or qualification for this corporation. Complete Block 5 by entering your Federal Employer Identification (FEI) number or checking off the appropriate box. If "applied for" was previously reported to this office, you MUST now include the FEI number or attach a photocopy of your application for the FEI number to this form or this application will be rejected. Call Internal Revenue Service at 1-800-829-4933 for FEI assistance. Your cancelled check will be your filing acknowledgment unless a certificate of status is requested in Block 6 and an additional $8.75 is submitted to cover its fee. Certificates of status will be mailed to the corporate mailing address unless accompanied by a cover letter indicating the name and address to whom the certificate should be mailed. Enter name of the registered agent and address. (The registered office address must be at a Florida street address.) The designated registered agent must indicate familiarity with Section 607.0505, F.S., or 617.0503, F.S., and acceptance of its obligations and this appointment by completing and signing in Block 8. ALL REINSTATEMENTS MUST BE SIGNED BY THE REGISTERED AGENT in accordance with Section 607.1422(1)(b) or 617.1422(1)(b), F.S. If the registered agent does not sign, the application will be rejected. Type or print the current officers/directors in the space provided in Block 9. Attach a separate sheet if necessary. In column 1 use the following or similar letters to designate appropriate corporate title(s): P=President, T=Treasurer, S=Secretary, V=Vice President, D=Director, C=Chairman, M=Manager, etc. If a person holds more than one position, enter all positions, e.g. S/D, V/D, P/V/D. A FLORIDA NONPROFIT CORPORATION MUST LIST ALL DIRECTORS (OR PERSON ACTING IN SUCH CAPACITY) THE NUMBER OF WHICH MAY NOT BE LESS THAN THREE (3) DIRECTORS OR TRUSTEES WITH THEIR STREET ADDRESSES. The letter "D" or "T" must appear beside the name and address of each director or trustee in the title portion. NOTE: A director must be a natural person 18 years of age or older. Florida Statutes requires a physical street address be given. The provision of a post office box in Block 9 is an affirmation under oath that no other address is available. If no officers/directors were previously given, they must now be designated. This report must be signed by an officer or a director of the corporation that is listed in Block 9 or on an attachment. If the corporation is in the hands of a receiver, it must be signed by the trustee or receiver.
Block 7 Block 8
MAKE CHECKS PAYABLE TO DEPARTMENT OF STATE. FEES: Reinstatement Fee Annual Report Fee Minimum Amount Due
PROFIT CORPORATION NON-PROFIT CORPORATION
$600.00 See Note $ 150.00 (for each year dissolved) _________ $750.00
$175.00 See Note $ 61.25 (for each year dissolved) _________ 236.25
Mailing Address: Department of State Division of Corporations P.O. Box 6327 Tallahassee, FL 32314 Courier Service Address: Division of Corporations Clifton Building 2661 Executive Center Circle Tallahassee, FL 32301 Internet Address: www.sunbiz.org (850) 245-6059 Hearing/Voice Impaired may call (850) 245-6096 (TDD)
NOTE: The reinstatement fee may be waived if the corporation did not receive the annual report notices in the year of dissolution /revocation. Only the annual report and supplemental fees for each year, from the year of dissolution/revocation to the current year, will be due. Please check the box on the application to indicate non-receipt.
Fees to Reinstate Effective January 1, 2009
YEAR DISSOLVED 2004 2005 2006 2007 2008 2009 PROFIT CORPORATION $ 1,500.00 $ 1,350.00 $ 1,200.00 $ 1,050.00 $ 900.00 $ 750.00 NON-PROFIT CORPORATION $ 542.50 $ 481.25 $ 420.00 $ 358.75 $ 297.50 $ 236.25
*If dissolved prior to 2004, call 850-245-6059 for filing fee information. *Add additional $8.75 for each certificate of status requested.