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Application for Certificate of Withdrawal (New Jersey)

This form is to withdraw a certificate for a Foreign Profit or Nonprofit Corporation in New Jersey. The form provided here is simply a sample of what the actual Form C-124 looks like.

Department of the Treasury
Division of Revenue

Application for Certificate of Withdrawal

(For Use by Foreign Profit and Nonprofit Corporations)

Check Appropriate Statute:

__ Title 14A:13-8 New Jersey Business Corporation Act (File in Duplicate)

__ Title 15A:13-8 New Jersey Nonprofit Corporation Act (File in Triplicate)

Pursuant to the provisions of the appropriate Statue, checked above, of the New Jersey Statutes, the undersigned corporation hereby applies for a Certificate of Withdrawal from the State of New Jersey and for this purpose submits the following application:

1. Name of Corporation: ____________________________

2. Corporation Number: ____________________________

3. Incorporated under the laws of: ____________________________

4. The corporation in not transacting business activities in New Jersey.

5. The corporation hereby surrenders its authority to transact business activities in New Jersey.

6. The address to which the Secretary of State may mail a copy of any process against the Corporation that may be served is:


____________________________ (CITY)

____________________________ (STATE)

____________________________ (ZIP CODE)

NOTE: Foreign Profit Corporations must attach a "Tax Clearance Certificate" from the

Division of Taxation
Department of Treasury
Trenton, NJ 08625-0269.

Signature: (Must be Ch. of Bd., President or Vice President)


Date: ____________________________

Type Name and Title ____________________________

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