Statement Form Of Foreign Entity Withdrawal - Colorado Page 2
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33. The principal office address of the entity’s principal office is
Street address
______________________________________________________
(Street number and name)
______________________________________________________
__________________________ ______ ____________________
(City)
(State)
(ZIP/Postal Code)
_______________________ _________________
(Province – if applicable)
(Country)
Mailing address
______________________________________________________
(leave blank if same as street address)
(Street number and name or Post Office Box information)
______________________________________________________
__________________________ ______ ____________________
(City)
(State)
(ZIP/Postal Code)
_______________________ _________________.
(Province – if applicable)
(Country)
4. The jurisdiction under the law of which the entity is formed is ____________________________________.
5.
(The following statement is adopted by marking the box.)
The entity will no longer transact business or conduct activities in Colorado and it relinquishes its
authority to transact business or conduct activities in Colorado.
6.
(The following statement is adopted by marking the box.)
All trade names the entity has on file in the records of the Secretary of State pursuant to Article 71 of
Title 7, C.R.S., and any assumed entity name pursuant to § 7-90-603, C.R.S., are withdrawn upon the
filing of this Statement of Foreign Entity Withdrawal.
7.
(If applicable, adopt the following statement by marking the box and include an attachment.)
This document contains additional information as provided by law.
8.
(Caution: Leave blank if the document does not have a delayed effective date. Stating a delayed effective date has
significant legal consequences. Read instructions before entering a date.)
(If the following statement applies, adopt the statement by entering a date and, if applicable, time using the required format.)
The delayed effective date and, if applicable, time of this document is/are __________________________.
(mm/dd/yyyy hour:minute am/pm)
Notice:
Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or
acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the
individual's act and deed, or that the individual in good faith believes the document is the act and deed of the
person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity
with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic
statutes, and that the individual in good faith believes the facts stated in the document are true and the
document complies with the requirements of that Part, the constituent documents, and the organic statutes.
This perjury notice applies to each individual who causes this document to be delivered to the Secretary of
State, whether or not such individual is named in the document as one who has caused it to be delivered.
WTDRW_AUTH
Page 2 of 3
Rev. 6/28/2011
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