Form Fpc - Foreign Certificate Of Withdrawal January 2005
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The Commonwealth of Massachusetts
FPC
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Foreign Certifi cate of Withdrawal
FORM MUST BE TYPED
FORM MUST BE TYPED
(General Laws Chapter 156D, Section 15.20; 950 CMR 113.51)
(1) Exact name of corporation: ___________________________________________________________________________
(2) Jurisdiction of incorporation: __________________________________________________________________________
Date of incorporation: ______________________________________________________________________________
(month, day, year)
(3) Th e corporation is not transacting business in the commonwealth.
(4) Th e corporation surrenders its authority to transact business in the commonwealth.
(5) Th e corporation revokes the authority of its registered agent to accept service on its behalf.
(6) Th e Secretary of the Commonwealth is hereby appointed 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 business in the commonwealth.
(7) Th e corporation’s mailing address to which the Division may mail a copy of any process served on it:
________________________________________________________________________________________________
(number, street, city or town, state, zip code)
(8) Th e corporation shall notify the Division in the future of any changes to the above mailing address by fi ling a certifi cate of
amendment.
(9) Th e corporation hereby certifi es that all taxes known to the corporation to be due the commonwealth have been paid or pro-
vided for.
(10)Th is certifi cate is eff ective at the time and on the date approved by the Division, unless a later eff ective date not more than 90
days from the date of fi ling is specifi ed: __________________________________________________________________
Signed by: ___________________________________________________________________________________________ ,
(signature of authorized individual)
® Chairman of the board of directors,
® President,
® Other offi cer,
® Court-appointed fi duciary,
on this _________________________ day of_________________________________________
day of_________________________________________
day of
, _____________________ .
P.C.
c156ds1520950c11351 01/13/05
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