State Form 39077 - Application For Certificate Of Withdrawal Of A Foreign Corporation - 2012
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APPLICATION FOR CERTIFICATE OF
CONNIE LAWSON
WITHDRAWAL OF A FOREIGN CORPORATION
SECRETARY OF STATE
CORPORATIONS DIVISION
State Form 39077 (R10 / 4-12)
302 W. Washington St., Rm. E018
Approved by State Board of Accounts, 1995
Indianapolis, IN 46204
T elephone: (317) 232-6576
INSTRUCTIONS:
Use 8 1/2" x 11" white paper for attachments.
Present original and one (1) copy to address in upper right corner of this form.
Indiana Code 23-1-50-2; 23-17-26-11
Please TYPE or PRINT.
FILING FEE IS $30.00
Please visit our office on the web at
APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF
Name of corporation
A FOREIGN CORPORATION ADMITTED TO TRANSACT BUSINESS IN THE STATE OF INDIANA
The undersigned officer of ____________________________________________________________________________
(hereinafter referred to as the "Corporation"), which exists pursuant to the provisions of ____________________________
(state or country)
as amended, desiring to effectuate the withdrawal of the Corporation from the State of Indiana, certifies the following facts:
ARTICLE I - NAME
Name of Corporation
State or country in which it is incorporated
ARTICLE II - REPRESENTATION BY THE WITHDRAWING CORPORATION
The Corporation received its Certificate of Authority from the State of Indiana on (month, day, year) _______________________________
and is no longer transacting business in Indiana. The Corporation surrenders its authority to transact business in Indiana.
ARTICLE III - SERVICE OF PROCESS
The Corporation revokes the authority of _________________________________________________________________,
its Registered Agent to accept service of process on its behalf and appoints the Secretary of State as its agent for service of
process in any proceeding based on a cause of action arising during the time it was authorized to transact business in
Indiana. A copy of any such process served on the Secretary of State should be mailed to the following address of the
corporation:
Address of Corporation (number and street, city, state, and ZIP code)
The Corporation shall notify the Secretary of State in the future of any change in its mailing address.
In witness whereof, the undersigned being the ___________________________________________________________ of
Title
said Corporation executes this Application for Certificate of Withdrawal and verifies, subject to penalties of perjury, that the
statements contained herein are true this ___________ day of ____________________________________ , 20________.
Signature
Printed name
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