Form D5 - Notification Of Dissolution Or Surrender
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D5
Rev. 8/12
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 above. Do not send this D5 form to the Ohio Secretary of State’s offi ce.
Part I – General information to be completed by all corporate taxpayers.
Part II – To be completed by those persons who intend to use the “certifi cate method” to dissolve the corporation’s Ohio
charter or surrender its Ohio license (see instructions).
Part III – To be completed by those persons who intend to use the “affi davit method” to dissolve the corporation’s Ohio
charter or surrender its Ohio license (see instructions).
Part I – General Information
Name of corporation
(as recorded with the Ohio Secretary of State)
Address
Date of incorporation or qualifi cation
Ohio charter (license) number
Ohio franchise tax I.D. no.
State of incorporation
Type of corporation:
For-profi t
Federal identifi cation number
Not-for-profi t
Cooperative (under Ohio Revised Code [R.C.]chapter 1729)
Location of accounting records
Name, address and telephone number of person to whom inquiries may be made
Date Ohio business activity ceased or will cease
Date stock retired or will be retired
Type of business activity and product sold
(If foreign corporation that will continue existence, indicate N/A.)
The last personal property tax return was fi led on
in
(County)
(Date)
Ohio corporation franchise taxes have been fi led and paid through
(Year)
Was a combined franchise tax report fi led for any tax year after 1971?
Yes
No
If yes, list parent corporation’s name, Ohio charter number and Ohio franchise tax I.D. number
Ohio employer withholding tax returns have been fi led through
(Month/year)
If none fi led, explain
List All Tax Account Numbers (Vendor’s License,
Address of All Business Locations in Ohio
Seller’s Use, Consumer’s Use, Direct Pay, Fuel Use)
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