Form F0072 - Proposed Trade Name Withdrawal
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1Mississippi Secretary of State
11 F0072
P.O. Box 136, Jackson, MS 39205-0136
FOR OFFICE USE ONLY
Withdrawal of Fictitious Business Name
Miss. Code Ann. § 25-93-1 et seq.
(
:____________________________________
Legal Name
corporate , LLC, partnership, individual etc.)
Address: ______________________________________________________________________________________
MS business ID number (if any): ____________________
Fictitious business name currently in use: __________________________________________________________
Street address(es) of business using name:
Future effective date of withdrawal of fictitious business name registration (if applicable): _____________________
The entity making this withdrawal of fictitious business name registration, through its undersigned authorized
representative, states that it is withdrawing its use of the fictitious business name(s) listed above and will no longer
transact business in the State of Mississippi under that fictitious business name. The entity also acknowledges that its
fictitious business name registration will no longer be affective upon filing of this statement of withdrawal or upon the
future date as noted on this form.
Signed this _______ day of __________________, 20_______.
_______________________________________
________________________________________
Signature
Printed Name
_______________________________________
Title
Make Check for $25.00 payable to SECRETARY OF STATE. Mail completed form with payment to SECRETARY OF STATE, PO
BOX 136, JACKSON, MS 39205-0136. For assistance contact a customer service representative at (800) 256-3494. Visit our website at
for forms and instructions.
F0072 7/1/2010
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