FORM FC-4
B
R
WWW.
USINESS
1/2001
Nonrefundable Filing Fee:
STATE OF HAWAII
Profit: $50.00
Nonprofit: $20.00
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
Business Registration Division
1010 Richards Street
Clear Form
Mailing Address: P.O. Box 40, Honolulu, Hawaii 96810
APPLICATION FOR WITHDRAWAL, FOREIGN CORPORATION
(Section 415-119, 415B-134, Hawaii Revised Statutes)
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK
The undersigned, duly authorized officers of the corporation submitting this application, certify as follows :
1.
The corporation is (check one):
Profit
Nonprofit
(F/$50/B24)
(F$20/B24)
2.
The name of the corporation is:
_______________________________________________________________________________________________________________
The corporation was incorporated in:
3.
____________________________________________________________________________
4.
Please check one:
The notice of intention to withdraw from the State of Hawaii was published on: _______________________________
(Month
Days
Year)
in the __________________________________________________________________________________ ;
OR
(Name of Newspaper)
Publication was not made.
5.
The corporation is not transacting business or is not conducting affairs, and surrenders its authority to transact business or
conduct affairs, as applicable, in the State of Hawaii.
6.
The corporation revokes the authority of its registered agent in the State of Hawaii to accept service of process and
consents that service of process in any action, suit, or proceeding based upon any cause of action arising in this State
during the time the corporation was authorized to transact business or to conduct its affairs in this State may hereafter be
made on such corporation by service thereof on the Director of Commerce and Consumer Affairs.
7.
All taxes, debts, obligations and liabilities of the corporation in the State of Hawaii have been paid and discharged or
adequate provision has been made therefor.
8.
The complete mailing address to which the director may mail a copy of any process against the corporation that may be
served on the director is:
_______________________________________________________________________________________________________________
We certify under the penalties of Section 415-136, 415B-158, Hawaii Revised Statutes, as applicable, that we have read the
above statements and that the same are true and correct.
Signed this ____________day of ___________________________________, __________
_______________________________________________________
_________________________________________________________
(Type/Print Name & Title)
(Type/Print Name & Title)
_______________________________________________________
_________________________________________________________
(Signature of Officer)
(Signature of Officer)
SEE INSTRUCTIONS ON REVERSE SIDE. The application must be signed by two individuals who are officers of the corporation.