Form Fw 53-04 - Foreign Corporation Certificate Of Withdrawal
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1FW
KANSAS SECRETARY OF STATE
Foreign Corporation Certificate
53-04
of Withdrawal
Kansas Office of the Secretary of State
CONTACT:
Memorial Hall, 1st Floor
(785) 296-4564
120 S.W. 10th Avenue
kssos@sos.ks.gov
Topeka, KS 66612-1594
Above space is for office use only.
All information must be completed or this document will not be accepted for filing.
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INSTRUCTIONS:
Please read instructions before completing.
1. Business entity ID
number:
This is not the Federal Employer
_______________________________________
ID Number (FEIN)
2. Name of corporation:
Name must match the name on
________________________________________________________________________________________
record with the Secretary of State
3. State of incorporation:
_______________________________________
4. The Secretary of State
may mail any legal
________________________________________________________________________________________
process against the
Name
Street Address
corporation to:
______________________________________________________________________________________
Address must be a street address.
A P.O. box is unacceptable
City
State
Zip
5. The corporation surrenders its authority to transact business in the state of Kansas and withdraws therefrom.
6. Effective date:
Upon filing
A future effective date must be
within 90 days of filing date
______________________________
Future effective date
Month
Day
Year
7. I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct and I
have remitted the required fee.
________________________________________________________ ________________________________________________________
Signature of authorized officer
Date (month, date, year)
________________________________________________________
Name of signer (printed or typed)
Save time and money by filing your withdrawal online at
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Instructions:
1. If this form is submitted after the close of the entity’s tax year, an annual report and fee must be filed along
with or prior to dissolution. If the entity has forfeited, it must reinstate before withdrawal.
2. Submit this form with the $35 filing fee.
STAY UP-TO-DATE ON YOUR ORGANIZATION’S STATUS, ANNUAL REPORT DUE DATE AND CONTACT ADDRESSES BY GOING TO
UNDER QUICK LINKS, SELECT SEARCH BUSINESS ENTITY INFORMATION.
There is a $25 service fee for all checks returned by your financial institution.
NOTICE:
All information must be completed or this document will not be accepted for filing.
Page 1 of 1
Rev. 12/28/10 jdr
K.S.A . 17-7306
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