OFFICE OF SECRETARY OF STATE
CORPORATIONS DIVISION
315 West Tower, #2 Martin Luther King, Jr. Drive
Atlanta, Georgia 30334-1530
(404) 656-2817
Registered agent, officer, entity status information via the Internet
KAREN HANDEL
Secretary of State
Application for Withdrawal of Certificate of Authority
1. Organization type (check only one):
Corporation
Limited Liability Company
Limited Partnership
Liability Limited Partnership
2.
Entity name ______________________________________________________________
3.
Home state (state in which entity was formed) ___________________________________
4.
The entity selected above in item 1. and named in item 2. no longer transacts business in Georgia and surrenders
its certificate of authority.
5.
The entity revokes the authority of its registered agent to accept service of process on its behalf and appoints the
Georgia Secretary of State as its agent for service in any proceeding based on a cause of action that arose
during the time it was authorized to transact business in Georgia.
6.
Any process served on the entity after withdrawal from Georgia may be mailed to:
__________________________________________
__________________________________________
__________________________________________
7. The withdrawing entity commits that it will notify the Secretary of State of any change in the mailing address
provided in item 6.
8. ________________________________________________________________________________
Signature
Printed or typed name of signer
Title of person signing above (circle one title beside the entity type below that matches the entity type checked in
item 1.) :
Corporation- Officer; Attorney for corp; Incorporator; Receiver or trustee
LLC- Member; Manager; Attorney for LLC; Organizer; Receiver or trustee
LP-
General partner; Attorney for LP; Receiver or trustee
LLP- General partner; Attorney for LLP; Receiver or trustee
All annual registrations must be filed before an entity may withdraw. Entity status may be checked at web
address above. If entity status is “active/noncompliance,” annual registration must be submitted before
withdrawal. The annual registration may be filed online. All other statuses (“active/compliance”, “active/owes
current year”) are eligible to withdraw immediately.
Withdrawal filing fee: $20, payable to “Secretary of State”
Mail completed application and filing fee to address at top of form.
Certificate of withdrawal will be mailed to address in item 6. unless a preferred address is provided in a
cover letter.
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