Form D5 - Notification Of Dissolution Or Surrender
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D5
Rev. 4/17
Tax Release Unit
P.O. Box 182382
Columbus, OH 43218-2382
Notifi cation of Dissolution or Surrender
All corporations seeking a dissolution, surrender, consolidation, merger or conversion must submit this form to the Ohio
Department of Taxation at least 30 days prior to the date the corporation intends to fi le with the Ohio Secretary of State.
A Certifi cate of Tax Clearance will not be issued until all taxes/fees administered by the tax commissioner are fi led and
paid. Review the notifi cation of dissolution or surrender instructions before completing.
1. Name of corporation
(as recorded with the Ohio Secretary of State)
DBA (if applicable)
Address
FEIN
Ohio charter/entity no.
Date qualifi ed in Ohio
Incorporation date
State of incorporation
2. Select corporation/entity type:
Domestic For-Profi t
Domestic Nonprofi t
LLC
Foreign For-Profi t
Foreign Nonprofi t
Domestic/Foreign Nonprofi t Agricultural Cooperative
3. Select dissolution/surrender method:
Certifi cate of Tax Clearance
Affi davit
(Domestic for-profi t corporations must select Certifi cate of Tax Clearance)
4. Select reason for dissolution/surrender:
Consolidation
Conversion
Dissolution/Surrender
Merger
Other
5. Date Ohio business activity ceased or will cease (mm/dd/yy):
Ending date of last payroll subject to Ohio withholding (mm/dd/yy):
Date corporation intends to dissolve its Ohio charter/license (mm/dd/yy):
6. Type of business activity/product sold:
NAICS code:
7. Name, address, telephone and fax number of person to whom inquiries may be made. If this is a
representative, please include a Declaration of Tax Representative (Ohio TBOR 1):
8. Select each tax applicable to this corporation and provide information requested. See section 3 of the instructions for
information on how to close certain accounts with the Ohio Department of Taxation:
Tax Type
Ohio Account No.
Date Final Return Filed
Commercial activity tax
Consumer use tax/direct pay permit
Corporation franchise tax
Employer withholding tax
Excise/energy taxes
(motor fuel, alcohol, tobacco, public utility)
Financial institutions tax (also see #9 on page 2)
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