State Form 4160 - Application For Reinstatement Page 2

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APPLICATION FOR REINSTATEMENT

State Form 4160 (R15 / 3-17)

Approved by State Board of Accounts, 2017

For-Profit Corporations:

Indiana Code 23-1-46-3

23-1-18-3

Nonprofit Corporations:

Indiana Code 23-17-23-3

23-17-29-3

Limited Liability Companies:

Indiana Code 23-18-10-4

23-18-12-3

Master LLCs:

Indiana Code 23-18.1-6-4

23-18-12-3

FILING FEE: $30.00

SECTION I – ENTITY INFORMATION

Name of entity

Date of incorporation or organization (month, day, year)

Effective date of administrative dissolution (month, day, year)

SECTION II - AFFIDAVIT

The undersigned, being at least one of the principal officers, directors, members, or managers of the above-named entity deposes and says:

that the grounds for dissolution did not exist or have been eliminated, and;

that the entity's name satisfies the requirements of Indiana Code 23-1-23-1, Indiana Code 23-17-5-1, Indiana Code 23-18-2-8, or

Indiana Code 23-18.1-6-7.

In Witness Whereof, the undersigned being the ________________________ of said entity, executes this application and verifies, subject to penalties of

Title

perjury, that the statements contained herein are

true, this ______ day of ________________________, 20______.

Signature

Printed name