Form D5 - Notification Of Dissolution Or Surrender - 2013 Page 3
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3D5
Rev. 9/13
The corporation for which this application/notice is fi led is a domestic nonprofi t corporation other than a domestic
nonprofi t agricultural cooperative, and is organized under R.C. chapter 1702. 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
1702.47(G)(5) 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 corporation acknowledges the applicability of R.C. section
1702.55.
Name
Signature
Title
Date
The corporation for which this application/notice is fi led is a foreign nonprofi t corporation (other than a foreign
nonprofi t agricultural cooperative) and is organized under the laws of another state or country and licensed to exer-
cise its corporate privileges in Ohio. The corporation informs the Ohio Department of Taxation that the corporation
intends to surrender its Ohio license 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 of the license, 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
Please send or e-mail the completed, signed form to:
Ohio Department of Taxation
For overnight delivery ONLY:
Taxpayer Services/Dissolution Unit
Ohio Department of Taxation
P.O. Box 182382
Taxpayer Services/Dissolution Unit
Columbus, OH 43218-2382
4485 Northland Ridge Blvd.
Columbus, OH 43229
E-mail: dissolution@tax.state.oh.us
Telephone Inquiries: 1-(888) 405-4039
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