Form 121-Btw - Resolution Of Withdrawal Of Business Trust By The Trustees Form - State Of Ohio Page 2

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J. Kenneth Blackwell
Secretary of State
AFFIDAVIT
to Accompany Resolution of Withdrawal of Business Trust
The undersigned, being first duly sworn, declare that on the dates indicated below each of the named
state government agencies was advised in writing of the scheduled date of filing of the Resolution of
Withdrawal and was advised in writing of the acknowledgement by the business trust that its
withdrawal from the State of Ohio does not release it of liability, if any, for payment of the taxes and
contributions due.
AGENCY
DATE
1.
Ohio Department of Taxation
Dissolution Section
P.O. Box 182382
Columbus, Ohio 43218-2382
2.
Ohio Bureau of Employment Services
Status and Liability Section
145 S. Front Street
Columbus, Ohio 43215
3.
The Treasurer of each County
in which personal property
is owned,
4.
The Ohio Bureau of Workers' Compensation
246 N. High Street
Columbus, Ohio 43215
(If Applicable)
The address to which the Secretary of State may mail any process against such business trust that may be
served upon him, and may mail any other notices, certificates, or statements is
(street address)
(city, township, or village)
(state)
(zip code)
Signature:
(Seal)
Name:
Title:
Sworn to before me and subscribed in my presence
(date)
(NOTARY PUBLIC)
121-BTW
Page 2 of 2
Version: 7/15/99

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