CERTIFICATE OF WITHDRAWAL
FOREIGN CORPORATION
APPLICATION
SECRETARY OF STATE
SFN 13101 (03-2006)
FOR OFFICE USE ONLY
1. FILING FEE $20.00
SEE REVERSE SIDE FOR FEES, FILING AND MAILING INSTRUCTIONS.
The following statements are hereby submitted for Certificate of Withdrawal from the State of North Dakota. The Secretary of State may request any
additional information necessary or appropriate to determine and assess any unpaid fees payable by the foreign corporation.
This form is prescribed for use by a foreign business corporation, a foreign professional corporation, or a foreign nonprofit corporation.
TYPE OR PRINT LEGIBLY
2. The name of the corporation:
5. An address to which a person may mail a copy of any process against the corporation: (Street/RR, PO Box, City, State, Zip+4)
3. Federal ID #:
4. State or country where incorporated:
"The following is hereby affirmed:
The corporation is not transacting business or conducting activities in North Dakota and surrenders its authority to do so.
The corporation revokes the authority of its registered agent in North Dakota to accept service of process. The corporation consents to service of
process on the corporation by service upon the North Dakota Secretary of State in any action, suit, or proceeding based upon any cause of action arising
in North Dakota during the time the corporation was authorized to transact business or conduct activities.
The undersigned, a person authorized by the corporation to sign this application, knows the contents of the application, and believes the statements
made to be true."
6.
ID#:
WO#:
Filed:
By:
7. Name of person to contact if questions about this application:
Daytime telephone #:
E-mail address:
Signature:
Date:
For reference, see North Dakota Century Code, Section 10-19.1-140 or 10-33-133.
FILING FEE: The application filing fee is $20.00.
(A check must be payable to "Secretary of State" and must be for U.S. negotiable funds. Payments may also be made by credit card using Visa, Master
Card or Discover.)
Provide the corporate name