Form D5 - Notification Of Dissolution Or Surrender - Ohio Department Of Taxation
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D5
Rev. 11/14
Taxpayer Services/Dissolution Unit
P.O. Box 182382
Columbus, OH 43218-2382
Notifi cation of Dissolution or Surrender
All corporations seeking a dissolution or surrender must submit this form to the Ohio Department of Taxation at least 30
days prior to the date that the corporation intends to fi le for dissolution/surrender with the Ohio Secretary of State. A Cer-
tifi cate of Tax Clearance will not be issued until all taxes/fees administered by the tax commissioner are fi led and paid.
See the instructions starting on page 3 before completing.
1. Name of corporation
(as recorded with the Ohio Secretary of State)
DBA (if applicable)
Address
Federal employer identifi cation no.
Ohio charter/license no.
Date qualifi ed in Ohio
Incorporation date
State of incorporation
2. Select corporation type:
Domestic For-Profi t
Domestic Nonprofi t
Domestic Nonprofi t Agricultural Cooperative
Foreign For-Profi t
Foreign Nonprofi t
Foreign Nonprofi t Agricultural Cooperative
3. Select dissolution/surrender method:
Certifi cate of Tax Clearance
Affi davit
(Domestic for-profi t 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:
Date stock retired or will be retired:
Ending date of last payroll subject to Ohio withholding (mm/dd/yyyy):
Date corporation intends to dissolve its Ohio charter/license (mm/dd/yyyy):
6. Type of business activity/product sold:
NAICS code:
7. Name, address, e-mail address and telephone number of person to whom inquiries may be made:
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 (also see #9 on page 2)
Consumer use tax/direct pay permit
Corporation franchise tax
Employer withholding tax
Excise/energy taxes
(motor fuel, alcohol, tobacco, public utility)
Financial institutions tax
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