Form 154 - Application For Certificate Of Withdrawal - Rhode Island Department Of State
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1
2State of Rhode Island and Providence Plantations
Department of State - Business Services Division
STAMP
Application for Certificate of Withdrawal
FOREIGN Business Corporation
FOR
SECRETARY OF STATE
USE ONLY
Filing Fee: $50.00
Pursuant to the provisions of
RIGL
7-1.2-1412
and 7-1.2-1413, the undersigned corporation hereby
applies for a Certificate of Withdrawal from the State of Rhode Island, and for that purpose submits
the following statement:
1. Entity ID Number:
2. The name of the corporation is:
3. It is incorporated under the laws of:
4. The corporation is not trasacting business in this state and surrenders its authority to transact business in this state.
5. It revokes the authority of its registered agent in this state to accept service of process, and consents that service of
process in any action, suit, or proceeding based upon any cause of action arising in this state during the time the
corporation was authorized to transact business in this state may subsequently be made on the corporation by service
thereof on the Department of State of the State of Rhode Island.
6. The post office address to which the Department of State may mail a copy of any service of process against the
corporation that is served on the Department of State:
7-1.2-1413, the corporation has paid all fees and taxes. RI Division of Taxation’s ORIGINAL letter
7. As required by
RIGL
of good standing (LOGS) for the purpose of withdrawal MUST accompany this form.
8. If the corporation is in the hands of a receiver or trustee, this Application for Certificate of Withdrawal must be executed
on behalf of the corporation by the receiver or trustee.
9. Date when this certificate of withdrawal will be effective: CHECK ONE BOX ONLY
Date received (Upon filing)
Later effective date (Date must be no more than 90 days from the day of filing) ___________________________
Under penalty of perjury, I declare and affirm that I have examined this Application for Certificate of Withdrawal, including
any accompanying attachments, and that all statements contained herein are true and correct.
Type or Print Name of Authorized Officer
Date
Signature of Authorized Officer of the Corporation
SIGN DOCUMENT HERE
MAIL TO:
Division of Business Services
STAMP
148 W. River Street, Providence, Rhode Island 02904-2615
Phone: (401) 222-3040
FOR
Website:
SECRETARY OF STATE
USE ONLY
If you have any questions, please call us at (401) 222-3040, Monday through Friday,
between 8:30 a.m. and 4:30 p.m., or email corporations@sos.ri.gov.
FORM 154 - Revised: 06/2016
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