Statement Form Of Foreign Entity Withdrawal - Colorado

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Form must be filed electronically.
Paper forms are not accepted.
This copy is a sample and cannot be submitted for filing.
Statement of Foreign Entity Withdrawal
filed pursuant to § 7-90-806 of the Colorado Revised Statutes (C.R.S)
1. The entity ID number, the entity name, and the true name, if different, are
Entity ID number
______________________________________________________
(Colorado Secretary of State ID number)
Entity name
______________________________________________________
True name
______________________________________________________.
(if different from the entity name)
2.
(Mark the applicable box and complete the statement. Caution: Mark only one box.)
The foreign entity will not maintain a registered agent in this state and service of process may be
addressed to the entity and mailed to the principal address pursuant to section 7-90-704 (2), C.R.S.
OR
The foreign entity will maintain a registered agent to accept service pursuant to section 7-90
204.5, C.R.S. Such registered agent’s name and address are:
Name
(if an individual)
______________________ ________________ ______________ ______
(Last)
(First)
(Middle)
(Suffix)
OR
(if an entity)
______________________________________________________
(Caution: Do not provide both an individual and an entity name.)
Street address
______________________________________________________
(Street name and number)
______________________________________________________
__________________________ CO
____________________
(City)
(State)
(Postal/Zip Code)
Mailing address
______________________________________________________
(leave blank if same as street address)
(Street name and number or Post Office Box information)
______________________________________________________
__________________________ ______ ____________________
(City)
(State)
(Postal/Zip Code)
_______________________ __________________
(Province – if applicable)
(Country – if not US)
(The following statement is adopted by marking the box.)
The person appointed as registered agent above has consented to being so appointed.
WTDRW_AUTH
Page 1 of 3
Rev. 6/28/2011

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