Form 635_0115 - Application For Certificate Of Withdrawal - 2011
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1MATT SCHULTZ
APPLICATION FOR
Secretary of State
CERTIFICATE OF
State of Iowa
WITHDRAWAL
TO THE SECRETARY OF STATE OF THE STATE OF IOWA:
Pursuant to Iowa law, the undersigned corporation applies for a certificate of withdrawal from Iowa, and states:
1. The name of the corporation is _____________________________________________________________
and the name the corporation uses in Iowa if different than its real name is:
_____________________________________________________________________________________
2. The corporation is incorporated under the laws of the state [or foreign country] of ______________________
3. The corporation is not transacting business in Iowa and surrenders its authority to transact business in Iowa.
4. The 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 Iowa.
5. The mailing address to which the secretary of state may mail a copy of any process served on the
secretary of state is:
Name ________________________________________________________________________________
Address _______________________________________________________________________________
City, State, ZIP _________________________________________________________________________
The corporation will notify the secretary of state in the future of any change in this mailing address.
Date ______________________________
Signature ______________________________________________________________________________
Type or print name and title _______________________________________________________________
The filing fee is:
$10.00 - Profit Corporations
$ 5.00 - Nonprofit Corporations
Make checks payable to SECRETARY OF STATE
635_0115
12/11
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