Form Scc767/929 - Application For A Certificate Of Withdrawal Of A Foreign Corporation Authorized To Transact Business In Virginia - Commonwealth Of Virginia State Corporation Commission

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COMMONWEALTH OF VIRGINIA
STATE CORPORATION COMMISSION
SCC767/929
(07/07)
APPLICATION FOR A CERTIFICATE OF WITHDRAWAL
OF A FOREIGN CORPORATION AUTHORIZED TO TRANSACT BUSINESS IN VIRGINIA
The undersigned, on behalf of the foreign corporation set forth below, pursuant to § 13.1-767 or § 13.1-929 of the
Code of Virginia, hereby makes this application for a certificate of withdrawal and states as follows:
1. The name of the corporation is
______________________________________________________________________________.
2. The name of the state or country under whose law the corporation is incorporated is
______________________________________________________________________________.
3. The corporation is not transacting business in Virginia and surrenders its authority to transact business in
Virginia.
4. The corporation revokes the authority of its registered agent to accept service on its behalf and appoints the
Clerk of the Commission 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 Virginia.
5. The mailing address to which the Commission may mail a copy of any process served on the Clerk of the
Commission as agent for the corporation is
______________________________________________________________________________.
6. The corporation makes a commitment to notify the Clerk of the Commission in the future of any change in its
mailing address.
7. The corporation certifies that [mark appropriate box]:
It has filed returns and has paid all state taxes to the time of this application; or
(APPROPRIATE FOR STOCK AND NONSTOCK CORPORATIONS)
It is not required to file any return or pay any state taxes.
(APPROPRIATE FOR NONSTOCK CORPORATIONS ONLY)
Executed in the name of the corporation by:
_________________________________________
__________________________________
(signature)
(corporate title)
_________________________________________
__________________________________
(printed name)
(date)
_________________________________________
__________________________________
(corporation’s SCC ID No.)
(telephone number (optional))
(The execution must be by the chairman or any vice-chairman of the board of directors, the president, or any
other of its officers authorized to act on behalf of the corporation.)
PRIVACY ADVISORY: Information such as social security number, date of birth, maiden name, or financial institution account numbers is NOT required to be included
in business entity documents filed with the Office of the Clerk of the Commission. Any information provided on these documents is subject to public viewing.
SEE INSTRUCTIONS ON THE REVERSE
Provide a name and mailing address for sending correspondence regarding the filing of this document (if left
blank, correspondence will be sent to the address given in paragraph 5, above):
________________________________________________________________________________________
(name)
________________________________________________________________________________________
(mailing address)

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