Form 39077 - Application For Certificate Of Withdrawal Of A Foreign Corporation - Indiana Secretary Of State Page 2

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APPLICATION FOR CERTIFICATE OF WITHDRAWAL

OF A FOREIGN CORPORATION

State Form 39077 (R11 / 7-16)

Approved by State Board of Accounts, 2016

Indiana Code 23-1-50-2

23-1-18-3

23-17-26-11

23-17-29-3

FILING FEE: $30.00

APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF:

Name of corporation

A FOREIGN CORPORATION ADMITTED TO TRANSACT BUSINESS IN THE STATE OF INDIANA

The undersigned officer of __________________________________________________________________________________________________

(hereinafter referred to as the “Corporation”), which exists pursuant to the provisions of _________________________________________________ as

(state of country)

amended, desiring to effectuate the withdrawal of the Corporation from the State of Indiana, certifies the following facts:

ARTICLE I - NAME

Name of Corporation

State or country in which it is incorporated

ARTICLE II - REPRESENTATION BY THE WITHDRAWING CORPORATION

The Corporation received its Certificate of Authority from the State of Indiana on (month, day, year) __________________________________________

and is no longer transacting business in Indiana. The Corporation surrenders its authority to transact business in Indiana.

ARTICLE III - SERVICE OF PROCESS

The Corporation revokes the authority of ______________________________________________________________________________________,

its Registered Agent to accept service of process on its behalf and appoints the Secretary of State 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 Indiana.

A copy of any such process served on the Secretary of State should be mailed to the following address of the corporation:

Address of Corporation (number and street, city, state, and ZIP code)

The Corporation shall notify the Secretary of State in the future of any change in its mailing address.

In witness whereof, the undersigned being the ___________________________________________________________ of said Corporation executes

(Title)

this Application for Certificate of Withdrawal and verifies, subject to penalties of perjury, that the statements contained herein are true

this ______ day of ________________________, 20______.

Signature

Printed name