Fees will increase September 1, 2003. If you file this report
before September 1, the fee is $20.00. If you file this report after
September 1, the fee is $35.00.
KANSAS SECRETARY OF STATE
Contact Information
DS
For Profit Corporation
Kansas Secretary of State
Dissolution by Stockholders’ Meeting
Ron Thornburgh
53-01
Memorial Hall, 1st Floor
All information must be completed or this document will not be accepted for filing.
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
Print
Reset
Please complete the form, print, sign and
Name of the corporation:
mail to the Kansas Secretary of State with
___________________________________________________________
the filing fee. Selecting 'Print' will print
the form and 'Reset' will clear the entire
___________________________________________________________
form.
Name must match the name on record with the secretary of state
Dissolution of the corporation was authorized pursuant to K.S.A. 17-6804.
Do not write in this space
Officers: Name
Title
Address
City
State
Zip
Directors: Name
Address
City
State
Zip
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed on the ________ of ___________ , _____________
.
Day
Month
Year
Attest:
President or Vice President
Secretary or Assistant Secretary
Instructions
1. If this form is submitted after the close of the corporation’s tax year, an annual report and franchise tax
must be submitted for that year. If the corporation has forfeited, it must reinstate before dissolution.
2. Submit this form in duplicate with the $35 filing fee.
Notice: There is a $25 service fee for all returned checks.
Rev. 8/11/03 amc
K.S.A. 17-6804