Free 39077.PDF - Indiana

APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF A FOREIGN CORPORATION
Sta te Form 3 9077 (R8 / 1-03 ) Appro ved by th e S tate Board of Accounts 199 5

TO DD RO KITA SE CRETARY OF STATE CO RP ORATIONS DIVISION 30 2 W. Wa shin gto n S t., Rm. E0 18 Ind ianapo lis, IN 46204 Teleph one: (3 17) 232-6 576 Ind iana Co de 23-1-5 0-2; 23 -17-26 -11

INSTRUCTIONS:

Use 8 1/2" x 11" white paper for attachments. Present original and one (1) copy to address in upper right corner of this form. Please TYPE or PRINT. Please visit our office on the web at www.sos.in.gov. APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF

FILING FEE IS $30.00

Name of corpo ratio n

A FOREIGN CORPORATION ADMITTED TO TRANSACT BUSINESS IN THE STATE OF INDIANA

The undersigned officer of ____________________________________________________________________________ (hereinafter referred to as the "Corporation"), which exists pursuant to the provisions of ____________________________
(state or cou ntry)

as amended, desiring to effectuate the withdrawal of the Corporation from the State of Indiana, certifies the following facts:

ARTICLE I - NAME
Name of Corpo ration

S tate or cou ntr y in wh ich it is incorpora ted

ARTICLE II - REPRESENTATION BY THE WITHDRAWING CORPORATION

The Corporation received its Certificate of Authority from the State of Indiana on __________________________________ and is no longer transacting business in Indiana. The Corporation surrenders its authority to transact business in Indiana.

ARTICLE III - SERVICE OF PROCESS

The Corporation revokes the authority of _________________________________________________________________, its Registered Agent to accept service of process 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 Indiana. A copy of any such process served on the Secretary of State should be mailed to the following address of the corporation:

A ddress of Cor poration

(n umber and stree t, city, state, ZIP code)

The Corporation shall notify the Secretary of State in the future of any change in its mailing address. In witness whereof, the undersigned being the ___________________________________________________________ of
Title

said Corporation executes this Application for Certificate of Withdrawal and verifies, subject to penalties of perjury, that the statements contained herein are true this ___________ day of ____________________________________ , 20________.
S ignature P rinte d n ame