Form: Certificate Of Withdrawal

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FORM: CERTIFICATE OF WITHDRAWAL
Page 1 of 1
VERMONT SECRETARY OF STATE Location: Heritage 1 Bldg Mail: 81 River Street, Drawer
09
Montpelier, VT 05609-1104 (802) 828-2386 Email:
biz@sec.state.vt.us
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
(foreign profit or non-profit corporation or foreign LLC)
Corporate
name______________________________________________________________________
Incorporated or organized under the laws of the state (country) of______________________ is no
longer transacting business in Vermont and surrenders its authority to transact business.
It 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 or was transacting without
authorization, in this State.
The mailing address where service of process may be sent is:
Street___________________________City________________________________State/Zip_____________
The foreign corporation will notify the Secretary of State of any change in its mailing address. All
corporate taxes and fees due the State of Vermont have been paid.
Signature_________________________________________Title________________Date_______________
$ 5.00 FEE. Please type or print and file in duplicate.
Effective date:___________________
2/21/00

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