Form Dscb:15-4129/6129-2 - Application For Termination Of Authority Foreign Corporation
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1
2PENNSYLVANIA DEPARTMENT OF STATE
CORPORATION BUREAU
Application for Termination of Authority
Foreign Corporation
Entity Number
(15 Pa.C.S.)
Business Corporation (§ 4129)
Nonprofit Corporation (§ 6129)
Name
Document will be returned to the
name and address you enter to
the left.
Address
⇐
City
State
Zip Code
Fee: $52
Filed in the Department of State on ________________________
Secretary of the Commonwealth
In compliance with the requirements of the applicable provisions of 15 Pa.C.S. (relating to corporations and unincorporated
associations), the undersigned qualified foreign corporation, desiring to withdraw from doing business in this Commonwealth, hereby
states that:
1
The name of the corporation is:
.
2. The (a) address of this corporation’s current registered office in this Commonwealth or (b) name of its
commercial registered office provider and the county of venue is (the Department is hereby authorized to
correct the following information to conform to the records of the Department):
(a) Number and Street
City
State
Zip
County
(b) Name of Commercial Registered Office Provider
County
c/o:
3. The name of the jurisdiction under the laws of which the corporation is incorporated is:
4. The date the corporation received a Certificate of Authority to do business in this
Commonwealth:
5. The corporation herewith surrenders its Certificate of Authority to do business in this Commonwealth.
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