State Form 39077 - Application For Amended Certificate Of Authority
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APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY
CONNIE LAWSON
SECRETARY OF STATE
State Form 39034 (R10 / 4-12) Corporate Form No. 115
BUSINESS SERVICES DIVISION
302 W. Washington Street, Room E018
Approved by the State Board of Accounts, 2007
Indianapolis, Indiana 46204
Telephone: (317) 232-6576
NOTE:
An Original Certificate of Existence duly authenticated by the proper authority from the corporation’s
domiciliary state within the last sixty (60) days must be submitted with this application.
Indiana Code 23-1-49-4; 23-17-26-4
Filing Fee: $ 30.00
1. Use 8 1/2" x 11" white paper for attachments.
INSTRUCTIONS:
Make check or money order
2. Present original and one copy to address in upper right corner of this form.
payable to Secretary of State
3. Please TYPE or PRINT.
4. Please visit our office on the web at
APPLICATION FOR
AMENDED CERTIFICATE OF AUTHORITY
OF
Name of Corporation
A FOREIGN CORPORATION ADMITTED TO
TRANSACT BUSINESS IN INDIANA
The undersigned officers of _________________________________________________________________________________
(hereinafter referred to as the "Corporation"), which exists pursuant to the provisions of the laws of _________________________
as amended, desire to obtain an Amended Certificate of Authority.
1. The above Corporation received a Certificate of Authority to transact business in the State of Indiana on the _____________
ARTICLE II - REPRESENTATION BY THE WITHDRAWING CORPORATION
day of ___________________________________________ , 20 _________ .
2. The Corporation desires to change its corporate name in Indiana as follows:
___________________________________________________________________________________________________
3. The Corporation has changed the period of its duration from ___________________________________________________
to ___________________________________________________.
4. The Corporation has changed the state or country of its incorporation from _______________________________________
to ______________________________________.
5. The Corporation has converted the entity type to a _________________________________________________________.
In Witness Whereof, the undersigned, being the __________________________________________________________ of said
Title
Corporation executes this Application for Amended Certificate of Authority 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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