Free CD.P65 - Kansas

Contact Information
Kansas Secretary of State Ron Thornburgh Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594
(785) 296-4564
[email protected]
www.kssos.org
1. Name of the corporation: _______________________________________________________ 2. Home state of incorporation: ______________________________ 3. Date of original incorporation: ____________________________ 4. Principal place of business:
Address must be a street address. A post office box is unacceptable.

KANSAS SECRETARY OF STATE


Certificate of Domestication
All information must be completed or this document will not be accepted for filing.

CD

53-14

Print

Reset

Please complete the form, print, sign and mail to the Kansas Secretary of State with the filing fee. Selecting 'Print' will print the form and 'Reset' will clear the entire form.
Do not write in this space

_______________________________________________________
Street address

_______________________
City

________________
State

____________
Zip

5. Resident agent and registered office in Kansas: ___________________________________________________________________
Name of resident agent

_________________________________________________ ___________________________
Street address (P.O. Box is NOT acceptable) City

Kansas ______________ ____________
State Zip

The corporation hereby domesticates itself in Kansas as a Kansas domiciled insurance corporation. The corporation has received approval from the Kansas Insurance Department to domesticate in Kansas, evidenced by the stamp of approval on this certificate. I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct. Executed on the ________ of ___________ , _____________ .
Day Month Year

Authorized officer

Instructions
1. The Certificate of Domestication must be filed along with Restated Articles of Incorporation to effect an insurance company's redomestication to the state of Kansas. 2. Both the Certificate of Domestication and the Restated Articles of Incorporation must be approved by the insurance commissioner as evidenced by the commissioner's stamp of approval before they are filed with the secretary of state.
3. The requirements for Restated Articles of Incorporation are stated in K.S.A. 17-6605. 4. Please submit this document with a filing fee of $35 per document.

Notice: There is a $25 service fee for all returned checks.

Rev. 12/07/04 amc Rev. 8/11/03 jls K.S.A. 40-2,162