Form Fw 53-04 - Foreign Corporation Certificate Of Withdrawal - Kansas Secretary Of State
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1Contact Information
KANSAS SECRETARY OF STATE
FW
Kansas Secretary of State
Foreign Corporation Certificate of Withdrawal
Ron Thornburgh
53-04
Memorial Hall, 1st Floor
All information must be completed or this document will not be accepted for filing.
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
Print
Reset
Please complete the form, print, sign and
1. Name of the corporation:
mail to the Kansas Secretary of State with
the filing fee. Selecting 'Print' will print
__________________________________________________
the form and 'Reset' will clear the entire
__________________________________________________
form.
Name must match the name on record with the secretary of state
2. State of incorporation: ______________________________
Do not write in this space
The corporation surrenders its authority to transact business in the
state of Kansas and withdraws therefrom.
3. The secretary of state may mail any legal process against the
corporation to:
Address must be a street address. A post office box is unacceptable.
Street address
City
State
Zip
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed on the ________ of ___________ , _____________
.
Day
Month
Year
Signature of authorized officer
Instructions
1. If this certificate of withdrawal is filed after the corporation’s fiscal year end, the annual report and fran -
chise fee for the last fiscal year must be filed in this office. If the corporation has forfeited, it must reinstate before
withdrawal.
2. Submit this form with the $35 filing fee.
Notice: There is a $25 service fee for all returned checks.
Rev. 8/11/03 jb
K.S.A. 17-7306
Rev. 11/24/04 jls
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