Form Mbca-12b - Foreign Business Corporation Application Of Withdrawal - 2004
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1Filing Fee $90.00
FOREIGN
BUSINESS CORPORATION
STATE OF MAINE
APPLICATION OF WITHDRAWAL
_____________________
Deputy Secretary of State
A True Copy When Attested By Signature
______________________________________
_____________________
(Name of Corporation)
Deputy Secretary of State
Pursuant to
13-C MRSA §1521
or §1523, the undersigned foreign corporation executes and delivers the following Application of
Withdrawal:
FIRST:
The jurisdiction of its incorporation is _______________________________________________________________.
SECOND:
The date on which it was authorized to do business in the State of Maine is ________________________________.
THIRD:
The foreign corporation is not transacting business in this State and that it surrenders its authority to transact business
in this State.
FOURTH:
(For Foreign Corporation Upon Conversion to a Nonfiling Entity):
The type of other entity to which the foreign business corporation has been converted is _______________________
_____________ and the jurisdiction whose laws govern its internal affairs is ________________________________.
FIFTH:
The foreign corporation revokes the authority of its registered agent to accept service on its behalf and appoints the
Secretary of State as its agent for service of process in any proceeding based on a cause of action arising during the
time it was authorized to transact business in this State.
The mailing address to which the Secretary of State may mail a copy of any process served on the Secretary of State:
______________________________________________________________________________________________.
(street, city, state and zip code)
SIXTH:
The foreign corporation is committed to notify the Secretary of State in the future of any change in its mailing
address.
DATED _________________________
*By __________________________________________________
(signature of any duly authorized officer)
__________________________________________________
(type or print name and capacity)
*This document MUST be signed by any duly authorized officer.
(13-C MRSA
§121.5)
Please remit your payment made payable to the Maine Secretary of State.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MBCA-12B (1 of 1) Rev. 8/1/2004
TEL. (207) 624-7740
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