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BCS/CD-313 Rev 04/2011

MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

BUREAU OF COMMERCIAL SERVICES, CORPORATION DIVISION

P. O. Box 30054, Lansing, Michigan 48909

Waiver Statement

I hereby request a waiver of any late fees assessed for the late filing of the annual report year(s)

___________________________ for ID# _________

entity name __________________________________________________

pursuant to Section 921 of Act 284 of 1972, as amended. For the reasons checked below, the

annual report was not timely filed.

The annual report was timely filed but with some other agency, either of this State,

another state, or with the Federal government.

The annual report was timely mailed along with the appropriate fee but was lost in the

mail.

The accountant, bookkeeper, or other person formally delegated the responsibility for

the filing of the annual report was unable to do so in a timely fashion as a result of

circumstances clearly beyond that person’s control.

The matters set forth above are true, and I am currently an officer of the corporation authorized

to execute documents such as this waiver statement on behalf of the corporation.

I understand that any waiver of penalties does not constitute a waiver of the $25.00 filing fee or

the obligation to file the annual report. I also understand that failure to file an annual report will

ultimately result in the automatic dissolution of a Michigan corporation or revocation of a foreign

corporation’s certificate of authority. Corporations dissolved or revoked are not eligible for a

waiver.

_____________________________________ ______________________________________

(Print Name)

(Print Title)

_____________________________________ ______________________________________

(Authorized Signature)

(Date)

BUSINESS CORPORATION ACT (EXCERPT)

Act 284 of 1972

450.1932 False or fraudulent report, certificate, or statement; falsification or alteration of books, records, or accounts; penalties.

Sec. 932.

A person who knowingly makes or files or a person who knowingly assists in the making or filing of a false or fraudulent report,

certificate, or other statement required by this act to be filed by a domestic or foreign corporation with a public officer of this state, or

a person knowing the same to be false or fraudulent, who procures, counsels, or advises the making or filing of a report, certificate,

or statement, is guilty of a misdemeanor and is subject to a fine of not to exceed $1,000.00 for each offense.

An officer or agent of a corporation who knowingly falsifies or wrongfully alters the books, records, or accounts of a corporation is

guilty of a misdemeanor and is subject to a fine of not to exceed $1,000.00 for each such offense.

History: 1972, Act 284, Eff. Jan 1, 1973 ;--Am. 1989, Act 121, Eff. Oct1, 1989

LARA is an equal opportunity employer/program.

Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

Form Bcs/cd-313 - Waiver Statement Form - Michigan Department Of Licensing And Regulatory Affairs