Free 635_0115.p65 - Iowa

MICHAEL A. MAURO Secretary of State State of Iowa
TO THE SECRETARY OF STATE OF THE STATE OF IOWA:

APPLICATION FOR CERTIFICATE OF WITHDRAWAL

Pursuant to Iowa law, the undersigned corporation applies for a certificate of withdrawal from Iowa, and states:

1. The name of the corporation is _____________________________________________________________ and the name the corporation uses in Iowa if different than its real name is: _____________________________________________________________________________________

2. The corporation is incorporated under the laws of the state [or foreign country] of ______________________

3. The corporation is not transacting business in Iowa and surrenders its authority to transact business in Iowa. 4. The corporation revokes the authority of its registered agent to accept service 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 Iowa. 5. The mailing address to which the secretary of state may mail a copy of any process served on the secretary of state is: Name ________________________________________________________________________________ Address _______________________________________________________________________________ City, State, ZIP _________________________________________________________________________ The corporation will notify the secretary of state in the future of any change in this mailing address.

Date ______________________________ Signature ______________________________________________________________________________ Type or print name and title _______________________________________________________________

The filing fee is:

$10.00 - Profit Corporations $ 5.00 - Nonprofit Corporations Make checks payable to SECRETARY OF STATE

635_0115 04/07

NOTES:

1. The filing fee is $10.00 - Profit Corporations $ 5.00 - Nonprofit Corporations Make checks payable to SECRETARY OF STATE

2. The document is to be signed by the chairperson of the board, the president, or other officer of the corporation. If directors have not been selected, the document is to be signed by an incorporator. If the corporation is in the hands of a court appointed fiduciary, the document is to be signed by the fiduciary. A copy of a signature is acceptable for filing. Verification is not required.

3. One copy of the document is to be delivered to the secretary of state for filing.

4. The effective time and date of the document is the later of the following: a. the time of filing on the date it is filed; b. the time specified in the document on the date it is filed; c. the time and date specified in the document, not later than 90 days after the date it is filed.

5. The information you provide will be open to public inspection under Iowa Code section 22.11.

SECRETARY OF STATE Business Services Division Lucas Building, 1st Floor Des Moines, Iowa 50319 Phone: (515) 281-5204 FAX: (515) 242-5953 or (515) 281-7142 Website: www.sos.state.ia.us
635_0115 04/07