Form D5 - Notification Of Dissolution Or Surrender
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D5
Rev. 9/13
Taxpayer Services/Dissolution Unit
P.O. Box 182382
Columbus, OH 43218-2382
Notifi cation of Dissolution or Surrender
See instructions on pages 4 and 5 of this form before completing. Please return this completed form D5 to the address
shown on page 3. Do not send this D5 form to the Ohio Secretary of State’s offi ce.
1. Name of corporation
(as recorded with the Ohio Secretary of State)
DBA (if applicable)
Address
Incorporation date
Ohio charter/license number
Federal employer identifi cation number
State of incorporation
2. Name, address, e-mail address and telephone number of person to whom inquiries may be made:
3. Date Ohio business activity ceased or will cease
Date stock retired or will be retired
Type of business activity and product sold
Please complete:
Tax Type
Ohio Account Number
Final Return Filing Date
(Attach additional sheet if necessary)
4. If you fi le the commercial activity tax as part of a combined group or as an elected consolidated taxpayer, provide the
name and CAT account number of the reporting person:
5. Name, address and federal employer identifi cation number of the entity (if any) that is continuing the business activities
of the dissolving corporation:
6. List each offi cer's and director's name, address and Social Security number (attach additional list if necessary):
Name and Title
Home Address
Social Security Number
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