Form Ad-19 - Indiana Affidavit For Reinstatement Of Domestic Corporation
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1AD-19
Indiana Department of Revenue
State Form 49514
Affi davit for Reinstatement of Domestic Corporation
(R3/ 10-10)
State of Indiana
)
) SS
County of _______________ )
_________________________________________________ being duly sworn according to law, affi rms that he/she is the
(name)
___________________________________________ of _______________________________ a corporation organized
(offi cial capacity)
(corporation name)
under the laws of the State of Indiana, _____________________________ , with its principal offi ce located at address
(incorporation date)
____________________________________________________ , city ________________________ , state _________ ,
zip _______________ , and identifi ed by Federal ID #______________________________ , and Indiana sales and/or
withholding tax TID # _______________________________ and that he/she makes this affi davit for and on behalf of this
corporation. He/She states that the books and records of this corporation are kept at ____________________________ ,
(address)
in care of ___________________________________________ , and that this corporation is engaged in the business of
(name)
__________________________________________________________ . To the best of my belief and knowledge, all of
(primary purpose)
the said corporation’s Indiana taxable income received on and after May 1, 1933, has been included in Indiana income tax
returns fi led with the Indiana Department of Revenue and that all tax has been paid. The latest Indiana sales and/or
withholding tax return were fi led for the month/year _____/_____ , under the name of ___________________________ .
(name)
That this affi davit is made for the sole purpose of inducing the Indiana Department of Revenue, to issue a notice as
provided by the applicable taxing acts to the effect that such corporation has paid all taxes due from it under the taxing
acts which will permit the Indiana Secretary of State to reinstate the corporation to active status.
______________________________________
Signature
______________________________________
Title
State of Indiana
)
) SS
County of _________________ )
Subscribed before me, a Notary Public in and for said county and state, this ______ day of _______________ , _______ .
_____________________________________________
_____________________________________________
Commission Expiration Date
Signature
_____________________________________________
_____________________________________________
County of Residence
Printed Name
Mail to: Indiana Department of Revenue, Tax Administration, P.O. Box 6197, Indianapolis, IN 46206.
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