Form 39077 - Application For Certificate Of Withdrawal Of A Foreign Corporation - Indiana Secretary Of State

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APPLICATION FOR CERTIFICATE OF WITHDRAWAL
SECRETARY OF STATE
OF A FOREIGN CORPORATION
BUSINESS SERVICES DIVISION
302 West Washington Street, Room E018
State Form 39077 (R11 / 7-16)
Indianapolis, IN 46204
Approved by State Board of Accounts, 2016
Telephone: (317) 232-6576
INSTRUCTIONS:
1. Use 8 ½”x11 white paper for attachments.
2. Please TYPE or PRINT in INK.
3. Please visit our office on the web at
4. Make check or money order payable to the Secretary of State.
5. Submit original completed paperwork and payment to: 302 West Washington Street, Room E-018, Indianapolis, IN 46204.
INFORMATION CONTAINED ON THIS PAGE IS NOT PART OF THE PUBLIC RECORD.
Name of business
E-mail address of business (SOS use only)
RETURN DOCUMENTS TO:
Name
Street address, line 1
Street address, line 2
City
State
ZIP code
Telephone number
E-mail address (If different from above – SOS use only)
(
)

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