Kentucky Secretary of State TREY GRAYSON
Division of Corporations BUSINESS FILINGS P.O. Box 718 Frankfort, KY 40602 (502) 564-3490 http://www.sos.ky.gov/
Application for Certificate of Withdrawal
Pursuant to the provisions of KRS Chapter 271B, 273 or 274, the undersigned hereby applies for a certificate of withdrawal on behalf of the corporation named below and for that purpose submits the following statements:
1. The corporation is
a business corporation (KRS 271B). a nonprofit corporation (KRS 273). a professional service corporation (KRS 274).
2. The name of the corporation is
(Name of corporation or fictitious name adopted for use in Kentucky)
3. The state or country of incorporation_________________________________________________________.
4. The corporation received authority to transact business in Kentucky on________________________. 5. The corporation is not transacting business in Kentucky. 6. The corporation hereby surrenders the authority to transact business in Kentucky. 7. The corporation hereby revokes the authority of its registered agent in Kentucky to accept service of process on its behalf and hereby appoints the Secretary of State as its agent for service of process in any proceeding based upon any cause of action arising during the time it was authorized to transact business in Kentucky. 8. The mailing address to which the Secretary of State may mail a copy of any process served is
Address City/State Zip Code
9. The corporation hereby commits to notify the Secretary of State in the future of any change in
the mailing address set forth in #8 (above). 10. This application will be effective upon filing, unless a delayed effective date and/or time is specified:
(Delayed effective date and/or time)
Type or Print Name & Title
Date: _______________________________________, 20____________
FCW (04/09) (See attached page for instructions)
Application for Certificate of Withdrawal Filing Instructions
TYPE OF CORPORATION The corporation must indicate if it is a business corporation (KRS 271B), a nonprofit corporation (KRS 273), or a professional service corporation (KRS 274) by checking the appropriate box. NAME OF CORPORATION Use the exact name of the corporation or the fictitious name adopted if "real name" was unavailable for use when the corporation applied for authority to transact business in Kentucky. STATE OF INCORPORATION Indicate the state or country of incorporation. DATE AUTHORIZED State the date that the corporation first received authority to transact business in Kentucky. EFFECTIVE DATE AND TIME The document will be effective on the date and time of filing, unless a delayed effective date and/or time is specified. A delayed effective date may not be later than the 90th day after the date of filing. WHO MAY SIGN An officer of the corporation or the chairman of the board of directors must sign the application for certificate of withdrawal. The person executing the document shall state his or her title or capacity in which he or she signs. NUMBER OF COPIES Submit the original signed application and two exact or conformed copies. (May be photocopies.) Two file-stamped copies will be returned to the corporation as evidence of filing. One filestamped copy must be filed with the county clerk of the county in which the corporation's registered office was situated. NOTE: Your file-stamped copy shall serve as the Certificate of Withdrawal. FILING FEES The filing fee for a business corporation or a professional service corporation is $40.00. The filing fee for a nonprofit corporation is $8.00. Your check should be made payable to the "Kentucky State Treasurer". MAILING ADDRESS Trey Grayson Secretary of State P O Box 718 Frankfort, KY 40602-0718 OFFICE LOCATION Room 154, Capitol Building 700 Capital Avenue Frankfort, KY 40601
WEB SITE ADDRESS Our home page address is www.sos.ky.gov Click on "On Line Business Database" for information on status of all business entities in Kentucky. Forms are also available on our web site. For information, please call (502) 564-3490 or try our web site.
NOTE: The corporation must be in "good standing" upon the records of the Secretary of State's Office before current statements or documents can be filed (30 KAR 1:010).