Free - West Virginia

Natalie E. Tennant Secretary of State State Capitol Bldg. 1900 Kanawha Blvd. East Charleston, WV 25305
FILE ONE ORIGINAL (Send two originals if you want a filed copy returned to you)

Penney Barker, Manager Corporations Division
Tel. (304) 558-8000/Fax 304-558-8381

Hrs. 8:30am ­ 5:00pm ET www.wvsos.com

WV APPLICATION FOR CERTIFICATE OF WITHDRAWAL

Filing Fee: $25
In accordance with the provisions of the West Virginia Code, the undersigned corporation hereby applies for a certificate of withdrawal from West Virginia, and submits the following statement: 1. 2. 3. The name of the corporation is: It is incorporated under the laws of: Mailing address to which the Secretary of State may mail a copy of any process against the corporation: Street/Box 4. City/State/Zip

The following statement does not apply to Insurance Companies who are registered and will continue to be registered with the West Virginia Insurance Commission. The company hereby attests that: It is not transacting business in West Virginia. It hereby surrenders its authority to transact business in West Virginia. It revokes the authority of its registered agent in West Virginia to accept service of process, and consents that service of process in any action, suite or proceeding based upon any course of action arising in West Virginia during the time the corporation was authorized to transact business in West Virginia may thereafter be made on the corporation by service thereof on the Secretary of State of West Virginia and commits to notify the Secretary of State of any changes of the corporation's mailing address.

5.

Contact Name

Phone Number

(listing a contact name/phone # is optional, however, it may help expedite your filing and avoid any possible rejection of your filing if a problem is found)

6. 7.

Print Name of Signer: Signature:

Title/Capacity of Signer: Date:

PRINT THIS COPY, THEN CLICK HERE TO RESET.

Form CF-5

Issued by the WV Secretary of State, State Capitol, Charleston, WV 25305

Revised 1/09

INSTRUCTIONS FOR FILING FOR A CERTIFICATE OF WITHDRAWAL FOR PROFIT OR NON-PROFIT

In order for the Office of the Secretary of State to issue a Certificate of Withdrawal for a foreign profit or non-profit corporation, the corporation must submit an original application for Withdrawal. If the company would like a filed copy returned to them along with the actual "Certificate of Withdrawal," send two original applications to the Office of Secretary of State. Upon receipt of the application, the Office of Secretary of State must first notify the following divisions and departments for formal clearances: 1. 2. 3. State Tax Department 304-558-0640 Workers Compensation 304-926-3400 Dept. of Employment Security 304-558-2675

As required by West Virginia Code, our office must receive all the formal releases before we can issue your certificate of withdrawal. You will, also, be held liable for all taxes, fees, penalties, interest, etc. (such as the annual corporate license tax) until clearances are obtained from all the applicable departments and divisions listed above.

IF YOU NEED ADDITIONAL INFORMATION CONCERNING WITHDRAWING YOUR CERTIFICATE OF AUTHORITY, PLEASE CONTACT OUR OFFICE AT 304-558-8000.

Form CF-5

Issued by the WV Secretary of State, State Capitol, Charleston, WV 25305

Revised 1/09