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

Filing Fee: $25

WV APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF A VOLUNTARY ASSOCIATION

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

The Association 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 association was authorized to transact business in West Virginia may thereafter be made on the association by service thereof on the Secretary of State of West Virginia and commits to notify the Secretary of State of any changes of the association's mailing address. Contact Name Phone Number

5.
(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 VA-4

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

Revised 1/09

INSTRUCTIONS FOR FILING FOR A CERTIFICATE OF WITHDRAWAL OF A VOLUNTARY ASSOCIATION
In order for the Office of the Secretary of State to issue a Certificate of Withdrawal for a voluntary association, the association 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 Workers Compensation 304-558-0640 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. 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 VA-4

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

Revised 1/05