Form D5 - Notification Of Dissolution Or Surrender - 2013 Page 2
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3D5
Rev. 9/13
7. List any matters pending with the department, such as petitions, appeals to the Board of Tax Appeals, request for refunds,
etc.
8. Please identify the person and e-mail or mailing address where the Certifi cate of Tax Clearance (form D2) should be sent
(if different from section 2):
9. I declare and affi rm, under penalties provided by law, that this application has been examined by me and the
statements contained therein are true to the best of my information, knowledge and belief.
Signature of Offi cer:
Date
President
Vice President
Secretary
Treasurer
(Check applicable title)
10.
Type of corporation:
Domestic For-Profi t – Proceed to page 3 for mailing information (see section 1 of the instructions, for further details
regarding Certifi cate of Tax Release).
All Other Corporate Types – Select one of the following below:
Corporation is choosing the certifi cate method for dissolution (see section 3A of the instructions).
Corporation is choosing the affi davit method for dissolution (see section 3B of the instructions).
This method is not available for domestic for-profi t corporations after Sept. 29, 2013.
Note: Please check the appropriate box below and indicate the date that this corporation intends to dissolve its
Ohio charter or surrender its Ohio license. In addition, this portion of the form must be signed by an offi cer of the
corporation or by a person executing the dissolution or surrender indicating that the corporation acknowledges
the applicability of the appropriate R.C. section as set forth below.
The corporation for which this application/notice is fi led is a domestic nonprofi t agricultural cooperative corporation
organized under R.C. chapter 1729. The corporation informs the Ohio Department of Taxation that the corporation
intends to dissolve its Ohio charter on (date)_______________by fi ling with the Ohio Secretary of State a certifi cate
of dissolution accompanied by the affi davit prescribed in R.C. section 1701.86(H)(2) (or in the case of a domestic
nonprofi t agricultural cooperative, the affi davit prescribed in R.C. section 1729.55(H)(6)) and any other documents
required by law. By the signature of an offi cer of the corporation or by the signature of a person who will execute the
dissolution, the cooperative acknowledges the applicability of R.C. section 1729.25.
Name
Signature
Title
Date
The corporation for which this application/notice is fi led is a either a foreign corporation organized for-profi t under the
laws of another state or country and licensed to conduct business in Ohio or a foreign nonprofi t agricultural coop-
erative corporation licensed to conduct business in Ohio and organized or operating in the same or similar manner as
nonprofi t corporations organized under R.C. chapter 1729. The corporation informs the Ohio Department of Taxation
that the corporation intends to surrender its license to conduct business in Ohio on (date)_______________by fi ling
with the Ohio Secretary of State a certifi cate of surrender accompanied by the affi davit prescribed in R.C. sections
1703.17(C)(2), 1703.17(C)(3) and 1703.17(D) and any other documents required by law. By the signature of an offi cer
of the corporation or by the signature of a person who will execute the surrender, the corporation acknowledges that
the surrender of the license does not relieve the corporation for payment of franchise tax, sales and use tax, fuel use
tax, personal property tax and unemployment compensation contributions due through the date of the surrender.
Name
Signature
Title
Date
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