Free ss-4436.indd - Tennessee

Print Form

For Office Use Only

Corporate Filings 312 Rosa L. Parks Avenue 6th Floor, William R. Snodgrass Tower Nashville, TN 37243

APPLICATION FOR CERTIFICATE OF WITHDRAWAL FOLLOWING ADMINISTRATIVE REVOCATION

To the Secretary of State of the State of Tennessee: Pursuant to the provisions of Section 48-25-305 of the Tennessee Business Corporation Act or Section 48-65-305 of the Tennessee Nonprofit Corporation Act, the undersigned corporation hereby applies for a certificate of withdrawal following administrative revocation from the State of Tennessee, and for that purpose sets forth: 1. The name of the corporation is

If different, the name under which the certificate of authority was obtained is

2. The state or country under whose law it is incorporated is 3. The corporation is not transacting business in the State of Tennessee and surrenders its authority to transact business in this state. 4. Indicate which of the following statements apply by marking the box: The corporation continues its registered office in the State of Tennessee. The corporation hereby 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 this state. 5. The mailing address to which the Secretary of State may mail a copy of any process served on him is: (Street)
(City) (State) (Zip Code)

6. The undersigned corporation makes the commitment to notify the Secretary of State in the future of any change in its mailing address. [NOTE: Prior to this document being accepted for filing, the Division of Business Services will request tax clearance verification from the Tennessee Department of Revenue that the business has properly filed all reports and paid all required taxes and penalties. If we cannot obtain such tax clearance verification from the Department of Revenue, this document will be rejected and returned to the applicant.]

Signature Date

Name of Corporation

Signer's Capacity

Signature

Name (typed or printed)
SS-4436 (Rev. 9/02) Filing Fee $100 RDA 1678