Instructions for Filing
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
BY REASON OF MERGER, CONSOLIDATION
Enter the name of the surviving or resulting entity in item 1. Enter the name of the State or Country (if formed
outside of the USA) of the surviving or resulting business entity in item 1(a). Enter the type of business entity of the
surviving or resulting business entity in item 1(b). e.g. Business Corporation, Limited Liability Company etc.
Enter the name of the merging or converting entity, the name of the State or Country (if formed outside of the USA)
of the merging or converting business entity, the type of business entity of the merging or converting business entity
( e.g. Business Corporation, Limited Liability Company etc.)
Enter the mailing address to which the Secretary of State may send a copy of any process served to us on behalf of
the merging or converting business entity.
This document must be accompanied by a certified copy of the Articles of Merger, a Certificate of Merger, a
certified copy of the conversion documents or a Certificate of Conversion duly authenticated by the Secretary of
State or other official having custody of records of such entities in the state or country under the laws of which such
merger or conversion was effected.
The document will be effective on the date and at the time of filing, unless a delayed date or an effective time (on
the day of filing) is specified. If a delayed effective date is specified without a time, the document will be effective
at 11:59 p.m. Raleigh, North Carolina time on the day specified. If a delayed effective date is specified with a time,
the document will be effective on the day and at the time specified. A delayed effective date may be specified up to
and including the 90
day after the day of filing.
Date and Execution
Enter the date the document was executed.
In the blanks provided enter:
The name of the surviving or resulting business entity as it appears in item 1.
The signature of the applicable representative executing the document.
Business Corporation/Nonprofit Corporation: the document must be signed by the Chairman or any
other Officer of the Corporation.
Limited Liability Company: the document must be signed by a Company Official of the LLC.
Limited Partnership/Limited Liability Partnership: the document must be signed by a General Partner
of the LP/LLP.
The name and title of the above-signed representative.
P.O. BOX 29622
RALEIGH, NC 27626-0622
(Revised January 2014)