Form Nfp 113.45 - Application For Withdrawal And Final Report
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NFP 113.45
FORM
(rev. Dec. 2003)
APPLICATION FOR WITHDRAWAL
AND FINAL REPORT
General Not For Profit Corporation Act
Foreign Corporations
Jesse White, Secretary of State
Department of Business Services
Springfield, IL 62756
Telephone (217) 782-6961
Remit payment in the form of a
check or money order payable
to the Secretary of State.
_____________________________________ File #_________________________________
Filing Fee: $ 5.00
Approved:
——————————Submit in duplicate ———————Type or Print clearly in black ink———————Do not write above this line——————————
1.
The name of the corporation is _______________________________________________________________
_______________________________________________________________________________________
2.
The State or county of incorporation is _________________________________________________________
3.
It surrenders its authority to conduct affairs in Illinois.
4.
It revokes the authority of its registered agent in Illinois to accept service of process in any suit, action or proceeding
based upon any cause of action arising in this State during the time this corporation was licensed to conduct affairs
in this State may hereafter be made on such corporation by service thereof upon the Secretary of State.
5.
The post office address to which the Secretary of State may mail a copy of any process served upon him against
the corporation is
The undersigned corporation has caused this application to be signed by a duly authorized officer who affirms, under
penalties of perjury, that the facts stated herein are true. (All signatures must be in BLACK INK.)
6.
Dated _________________________ , ________
____________________________________________
(Month & Day)
(Year)
(Exact name of corporation)
___________________________________
(Any Authorized Officer's Signature)
___________________________________
(Type or print name and title)
(All signatures must be in BLACK INK.)
C-161.8
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