Application For Certificate Of Withdrawal (Connecticut)
This is an application to withdraw a foreign corporation in Connecticut. The form provided here is simply a sample of what the actual Form SC 109 looks like.
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
Office of the Secretary of the State
30 Trinity Street / P.O. Box 150470 / Hartford, CT 06115-0470 / Rev. 12/l 999
Space For Office Use Only
1. NAME OF CORPORATION IN ITS STATE/COUNTRY OF FORMATION:
2. IF DIFFERENT FROM THE ABOVE, THE NAME UNDER WHICH CORPORATION TRANSACTS BUSINESS IN CONNECTICUT:
3. STATE OR COUNTRY OF INCORPORATION: ____________________
The corporation is not transacting business/conducting affairs in Connecticut and surrenders its authority to transact further business/conduct affairs therein.
The corporation revokes the authority of its registered agent to accept service of process on its behalf.
The corporation appoints the Secretary of the State as its agent for service of process and consents to service of process thereon in any action, suit or proceeding based on a cause of action arising during the time it was authorized to transact business/conduct affairs in this state.
4. THE ADDRESS TO WHICH THE SECRETARY OF THE STATE MAY MAIL ANY PROCESS SERVED UPON HIM IN ACCORDANCE WITH THE ABOVE STATED APPOINTMENT:
Number and Street or P.O. Box _____________________
Zip Code _____________________
The corporation sprees to notify the Secretary of the State in the future of any changes to the above stated address.
Dated this ___________________day of ______________, 20________.
Print or type name of signatory _____________________
Capacity of signatory _____________________
INSTRUCTIONS FOR FILLING OUT THIS FORM
Instructions Correspond With Numbered Entries On The Form
1. NAME OF CORPORATION IN STATE OR COUNTRY OF FORMATION: Please provide the complete name of the corporation as it appears on the records of the Secretary of the State.
2. IF DIFFERENT FROM THE ABOVE, THE NAME UNDER WHICH THE CORPORATION TRANSACTS BUSINESS IN CONNECTICUT: Please provide the complete name under which the corporation transacts business in this state if it is different from the name under which it is incorporated.
3. STATE OR COUNTRY OF INCORPORATION: Please provide the corporation's state or country of incorporation.
4. THE MAILING ADDRESS TO WHICH THE SECRETARY OF THE STATE MAY MAIL ANY PROCESS SERVED UPON HIM IN ACCORDANCE WITH THE ABOVE STATED APPOINTMENT: Please provide a complete address. Note: that it is the corporation's responsibility to file notices of any changes to this address following withdrawal.
5. EXECUTION: The document must be executed by an authorized official of the corporation. That person must print or type their name, state the capacity under which they sign and provide a signature. The execution constitutes a legal statement under the penalties of false statement that the information provided in the document is true.
MAKE CHECKS PAYABLE TO THE SECRETARY OF THE STATE
WITHDRAWAL OF FOREIGN CORPORATION
(Stock or Nonstock Corporation)
Filing Fee: Stock $50
COMPLETING THE APPLICATION FOR CERTIFICATE OF WITHDRAWAL
A foreign corporation authorized to transact business in Connecticut may withdraw its certificate of authority by filing an Application for Certificate of Withdrawal. The withdrawing corporation must appoint the Secretary of the State as its agent for service of process for matters relating to its activities in this state prior to withdrawal. It must further commit to notify the Secretary of the State of any changes to the address to which it would have copies of legal process sent following withdrawal.