Form Dmo 53-47 - Certificate Of Domestication To Foreign State Or Country - Kansas Secretary Of State
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1KANSAS SECRETARY OF STATE
DMO
Certificate of Domestication
to Foreign State or Country
53-47
Kansas Entity Domesticating Out
of Kansas
Kansas Secretary of State, Chris Biggs
CONTACT:
Memorial Hall, 1st Floor
Above space is for office use only.
(785) 296-4564
120 S.W. 10th Avenue
Topeka, KS 66612-1594
All information must be completed or this document will not be accepted for filing.
INSTRUCTIONS:
i
Please read instructions before completing.
Domesticating Entity
(This is the entity that is leaving the state of Kansas)
1. Business entity ID
number:
This is not the Federal Employer
_______________________________________
ID Number (FEIN)
2. Entity name:
_____________________________________________________________________________________
3. Type of entity:
___ For-Profit Corporation
___ General Partnership
___ Limited Liability Partnership
___ Not-for-Profit Corporation
___ Limited Liability Company
___ Limited Partnership
Domestication of this entity is approved in accordance with K.S.A. 17-78-501 through 17-78-506.
Domesticated Out Entity
(This is how the entity will be known in the foreign state or country)
4. Entity name:
_____________________________________________________________________________________
5. State or country
to which entity is
_______________________________________
domesticated:
I hereby irrevocably appoint the Kansas Secretary of State as agent for service of process.
6. Service of process
______________________________________________________________________________________
may be delivered to:
Name
Street Address
Must be a street address.
A P.O. box is unacceptable.
______________________________________________________________________________________
City
State
Zip
Country
7. Effective date:
Upon fi ling
__________________________
Future effective date (cannot exceed 90 days from the fi le date)
Month
Day
Year
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct and that I
have remitted the required fee.
____________________________________________________________
_________________________________
Signature of authorized person of the domesticating entity
Date
____________________________________________________________
____________________________________________
Name of signer, printed or typed
Title
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Instructions:
1. Submit this form with the $75 filing fee. Make checks payable to the Kansas Secretary of State.
2. If the tax closing month has passed, please submit an annual report and fee along with this form.
There is a $25 service fee for all checks returned by your fi nancial institution.
NOTICE:
Page 1 of 1
K.S.A . 17-78-505, 17-78-506
Rev. 7/01/10 nr
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