C
K
OMMONWEALTH OF
ENTUCKY
T
G
, S
S
REY
RAYSON
ECRETARY OF
TATE
____________________________________________________________________________________________________________________________
Division of Corporations
Certificate of Withdrawal
FCW
Business Filings
(Foreign Corporation)
PO Box 718
Frankfort, KY 40602
(502) 564-3490
____________________________________________________________________________________________
Pursuant to the provisions of KRS Chapter 271B, 273 or 274, the undersigned hereby applies for a certificate of withdrawal
on behalf of the corporation named below and, for that purpose, submits the following statements:
1. The corporation is
a profit corporation (KRS 271B)
a nonprofit corporation (KRS 273)
a professional service corporation (KRS 274)
2. The name of the corporation is ________________________________________________________________________.
(The name of the corporation or fictitious name adopted for use in Kentucky.)
3. The state or country of incorporation is__________________________________________________________________.
4. The corporation received authority to transact business in Kentucky on_________________________________________.
5. The corporation is not transacting business in Kentucky.
6. The corporation hereby surrenders the authority to transact business in Kentucky.
7. The corporation hereby revokes the authority of its registered agent in Kentucky to accept service of process on its behalf
and hereby appoints the Secretary of State as its agent for service of process in any proceeding based upon any cause of
action arising during the time it was authorized to transact business in Kentucky.
8. The street address to which the Secretary of State may mail a copy of any process served is:
___________________________________________________________________________________________________
Street Address (No P.O. Box Numbers)
City
State
Zip Code
9. The corporation hereby commits to notify the Secretary of State in the future of any change in the mailing address set forth
in question 8 above.
10. This application will be effective upon filing, unless a delayed effective date and/or time is provided. The effective date or
_
the delayed effective date cannot be prior to the date the application is filed. The date and/or time is _______________
__.
(Delayed effective date
and/or time)
I declare under penalty of perjury under the laws of the state of Kentucky that the foregoing is true and correct.
___________________________________________________________________________________________________
Signature of Authorized Party
Printed Name & Title
Date
(08/10)