Form Cd 53-14 - Certificate Of Domestication
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1Contact Information
KANSAS SECRETARY OF STATE
CD
Kansas Secretary of State
Certificate of Domestication
Ron Thornburgh
53-14
Memorial Hall, 1st Floor
All information must be completed or this document will not be accepted for filing.
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
Print
Reset
1. Name of the corporation:
Please complete the form, print, sign and
mail to the Kansas Secretary of State with
_______________________________________________________
the filing fee. Selecting 'Print' will print
the form and 'Reset' will clear the entire
2. Home state of incorporation: ______________________________
form.
3. Date of original incorporation: ____________________________
Do not write in this space
4. Principal place of business:
Address must be a street address. A post office box is unacceptable.
_______________________________________________________
Street address
_______________________
________________
____________
City
State
Zip
5. Resident agent and registered office in Kansas: ___________________________________________________________________
Name of resident agent
Kansas
_________________________________________________ ___________________________
______________ ____________
Street address (P.O. Box is NOT acceptable)
City
State
Zip
The corporation hereby domesticates itself in Kansas as a Kansas domiciled insurance corporation. The corporation has received
approval from the Kansas Insurance Department to domesticate in Kansas, evidenced by the stamp of approval on this certificate.
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed on the ________ of ___________ , _____________
.
Day
Month
Year
Authorized officer
Instructions
1. The Certificate of Domestication must be filed along with Restated Articles of Incorporation to effect an insurance company’s
redomestication to the state of Kansas.
2. Both the Certificate of Domestication and the Restated Articles of Incorporation must be approved by the insurance
commissioner as evidenced by the commissioner’s stamp of approval before they are filed with the secretary of state.
3. The requirements for Restated Articles of Incorporation are stated in K.S.A. 17-6605.
4. Please submit this document with a filing fee of $35 per document.
Notice: There is a $25 service fee for all returned checks.
Rev. 12/07/04 jls
Rev. 8/11/03 amc
K.S.A. 40-2,162
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