Form Bt-4 - Application For Certificate Of Withdrawal Of A Business Trust
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1
2Natalie E. Tennant
Penney Barker, Manager
Secretary of State
Corporations Division
1900 Kanawha Blvd E.
Tel: (304)558-8000
Bldg 1, Suite 157-K
Fax: (304)558-8381
Charleston, WV 25305
Hrs: 8:30 a.m. – 5:00 p.m. ET
APPLICATION FOR CERTIFICATE OF
FILE ONE ORIGINAL
WITHDRAWAL OF A BUSINESS TRUST
FEE: $25.00
In accordance with the provisions of the West Virginia Code, the undersigned Business Trust hereby applies
for a certificate of withdrawal from West Virginia, and submits the following statement:
1. The name of the business trust is:
_____________________________________________
2. It is formed under the laws of:
_____________________________________________
3. The mailing address to which the Secretary of State may mail a copy of any process against the
association:
__________________________________ ______________________________________________
No. & Street
City, State and Zip
4. The Business Trust hereby attests that: It is not transacting business in West Virginia. It hereby
surrenders its authority to transact business in West Virginia. It revokes the authority of its registered
agent in West Virginia to accept service of process, and consents that service of process in any action,
suit or proceeding based upon any course of action arising in West Virginia during the time the trust
was authorized to transact business in West Virginia may thereafter be made on the trust by service
thereof on the Secretary of State of West Virginia and commits to notify the Secretary of State of any
changes of the trust’s mailing address.
5. Contact name and number. This is optional, however, listing one may help expedite your filing and
avoid any possible rejection of your filing if a problem is found.
____________________________________________ ____________________________________
Contact Name
Phone Number
6. Print name of signer: __________________________ Title/Capacity of Signer: ________________
Signature: _________________________________________ Date: _________________________
Form BT-4
Issued by the Office of the Secretary of State
Revised 10/09
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