Form 254 - Application For Certificate Of Withdrawal
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1Filing Fee: $10.00
ID Number: ____________
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Office of the Secretary of State
Corporations Division
148 W. River Street
Providence, Rhode Island 02904-2615
NON-PROFIT CORPORATION
_____________
APPLICATION FOR
CERTIFICATE OF WITHDRAWAL
Pursuant to the provisions of Section 7-6-83 of the General Laws of Rhode Island, 1956, as amended, the undersigned
foreign non-profit corporation hereby applies for a Certificate of Withdrawal from the state of Rhode Island, and for that
purpose submits the following statement:
1. The name of the corporation is
2. It is incorporated under the laws of
3. It is not conducting affairs in the state of Rhode Island.
4. It hereby surrenders its authority to conduct affairs in the state of Rhode Island.
5. It revokes the authority of its registered agent in Rhode Island to accept service of process and consents that service
of process in any action, suit, or proceeding based upon any cause of action arising in Rhode Island during the time
the corporation was authorized to conduct affairs in Rhode Island may hereafter be made on the corporation by
service thereof on the Secretary of State of the State of Rhode Island.
6. The post office address to which the secretary of state may mail a copy of any process against the corporation that
may be served on him or her is:
Under penalty of perjury, we declare and affirm that we have
examined this Application for Certificate of Withdrawal, and that
all statements contained herein are true and correct.
Date:
Print Exact Name of Corporation Making Application
By _________________________________________________
President or
Vice President
(check one)
AND
By _________________________________________________
Secretary or
Assistant Secretary (check one)
Form No. 254
Revised: 12/05
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