Form Cf-5 - Application For Certificate Of Withdrawal From Certificate Of Authority - 2017
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1West Virginia Secretary of State
Penney Barker, Manager
1900 Kanawha Blvd E
Corporations Division
Bldg 1, Suite 157-K
Tel: (304)558-8000
Charleston, WV 25305
Fax: (304)558-8381
Website:
E-mail:
APPLICATION FOR
FILE ONE ORIGINAL
Office Hours: Monday – Friday
CERTIFICATE OF WITHDRAWAL
(Two if you want a filed
8:30 a.m. – 5:00 p.m. ET
FROM CERTIFICATE OF AUTHORITY
stamped copy returned to you)
FEE: $25.00
*** In accordance with the provisions of the West Virginia Code §31D-15-1520, the undersigned ***
corporation hereby applies for a certificate of withdrawal from West Virginia, and submits
the following statement:
1. The name of the corporation is: ______________________________________________________
2. It is incorporated under the laws of the State of: __________________________________________
3. The mailing address to which the Secretary of State may mail a copy of any process against the
corporation:
_________________________________________ _______________________________________
No. & Street
City/State/Zip
4. 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, suit 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 corporations
mailing address.
5. Name and phone number of contact person. (This is optional, however, if there is a problem with
the filing, listing a contact person and phone number may avoid having to return or reject the
document.)
__________________________________________________ ______________________________
Contact Name
Phone Number
6. Signature information (See below *Important Legal Notice Regarding Signature):
Print Name of Signer: ________________________________ Title/Capacity: __________________
Signature: _________________________________________ Date: ________________________
*Important Legal Notice Regarding Signature: Per West Virginia Code §31D-1-129. Penalty for signing false
document. Any person who signs a document he or she knows is false in any material respect and knows that the
document is to be delivered to the secretary of state for filing is guilty of a misdemeanor and, upon conviction
thereof, shall be fined not more than one thousand dollars or confined in the county or regional jail not more than
one year, or both.
Important Note: This form is a public document. Please DO NOT provide any personal identifiable
information on this form such as social security number, bank account numbers, credit card numbers, tax
identification or driver’s license numbers.
Form CF-5
Issued by the Office of the Secretary of State
Revised 01/17
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