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Out Of Existence Withdrawal Affidavit REV-238 - Pennsylvania
| Out Of Existence Withdrawal Affidavit Form. This is a Pennsylvania form and can be used in Department Of Revenue Statewide . |
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REV-238 CM (09-09) 23800011016 DEPARTMENT USE ONLY BUREAU OF COMPLIANCE OUT OF EXISTENCE/MERGER SECTION PO BOX 280947 HARRISBURG PA 17128-0947 717.783.6052 TT# 800.447.3020 (Services for Taxpayers with Special Hearing and/or Speaking Needs Only) OUT OF EXISTENCE/WITHDRAWAL AFFIDAVIT BOX NUMBER PLEASE PRINT OR TYPE INFORMATION TAX TYPE K- THIS FORM MUST BE PROPERLY SIGNED AND NOTARIZED NOTE: · If filing a final RCT-101 corporate report for the year 2002 and forward, complete the "corporate status change" section in the RCT-101 in lieu of filing this form. · The reverse side of this form must be completed. Section A pertains to a PA corporation or a foreign corporation that operated wholly within Pennsylvania. Section B pertains to all other foreign corporations. · If you wish to be notified that the corporation is out of business by e-mail, please provide e-mail address on reverse side. Date of Incorporation or Certificate of Authority State of Incorporation Name of Corporation/Taxpayer I, the "Affiant,"was connected with the above corporation and have knowledge of its affairs. Said corporation ceased to transact business in Pennsylvania on or about * distributed on Month Month Day Day Year Year Account ID/Corp. Box # Entity ID (EIN) , and all assets were sold, assigned or , and since that time, the corporation has not owned any property located in Pennsylvania, nor maintained an office therein, nor has performed any sales activity, and does not intend to transact further business in the Commonwealth. * If corporation never transacted business or held assets in Pennsylvania, please use the words "NEVER TRANSACTED BUSINESS" in place of a cessation date. The filing of this affidavit does not affect the status of the Certificate of Incorporation/Authority of this corporation but does permit the Department of State to relinquish the use of the present name of the corporation to another corporation. This affidavit is not to be filed by a PA corporation utilizing its PA charter to conduct business in another state. Out-of-state corporations soliciting business in Pennsylvania are subject to tax and should file this document only upon ceasing activity in Pennsylvania. Sworn to and subscribed before me this day of (Notary Public, District Justice, or Authorized Agent, Department of Revenue) , year (Signature of Affiant) TITLE My commission expires , year Telephone Number ( (Present address of Affiant) ) (Notary Signature and Seal) PLEASE PRINT OR TYPE INFORMATION NO FILING FEE 23800011016 American LegalNet, Inc. www.FormsWorkFlow.com 2 3 8 0 0 0 1 2 0 1 7 THIS SCHEDULE MUST BE COMPLETED. ENTER "NONE" ONLY IF THE CORPORATION HAS NO ASSETS AND/OR LIABILITIES. Please Print or Type Account ID/ Corp. Box # Date of Final Distribution State Zip Code DISTRIBUTION OF ASSETS Name of Corporation Business Address City A. CORPORATION OPERATING 100% WITHIN PA MUST COMPLETE THIS SECTION (Provide copies of Federal Form 1099-DIV) NUMBER DATE Social Security Number. State Social Security Number. State Social Security Number. State Social Security Number. State Social Security Number. State ZIP Code ZIP Code ZIP Code ZIP Code ZIP Code SHARES OF STOCK OF EACH STOCKHOLDER MONEY RECEIVED BY EACH STOCKHOLDER DATE AMOUNT DESCRIPTION PAR VALUE AMOUNT AND NATURE OF OTHER ASSETS RECEIVED BY EACH STOCKHOLDER AMOUNT Stockholder Name Street Address City Stockholder Name Street Address City Stockholder Name Street Address City Stockholder Name Street Address City Stockholder Name Street Address City B. CORPORATIONS WITHDRAWING FROM PA BUT CONTINUING OPERATIONS OUTSIDE OF PA MUST PROVIDE THE FOLLOWING INFORMATION AND/OR DOCUMENT(S). 1. FULL DETAILS OF DISPOSITION OF PA PROPERTY. ATTACH COPIES OF FEDERAL SCHEDULE D AND/OR FEDERAL FORM 4797, IF APPLICABLE. 2. PLEASE INDICATE IF SALES IN PA WILL CONTINUE AFTER DATE OF CESSATION. IF SO, HOW WILL THEY BE NEGOTIATED AND BY WHOM? ATTACH STATEMENT CONTAINING THE REQUIRED INFORMATION IF ADDITIONAL SPACE IS NEEDED. IF ANY INDIVIDUAL OR CORPORATION OTHER THAN STOCKHOLDERS AND CREDITORS RECEIVED ASSETS, LIST NAMES AND ADDRESSES OF EACH AND AMOUNT OR VALUE RECEIVED BY EACH. IF ANY CONSIDERATION WAS PAID FOR ANY OF THE ASSETS, STATE NAME AND ADDRESS OF INDIVIDUAL OR CORPORATION MAKING SUCH PAYMENT AND EXACT AMOUNT PAID BY EACH. (ATTACH A SEPARATE SHEET TO THIS FORM.) IF ANY MONEY OR PROPERTY REMAINS UNDISTRIBUTED, STATE AMOUNT, NATURE AND VALUE OF SAME, AND STATE WHY IT HAS NOT BEEN DISTRIBUTED. (ATTACH A SEPARATE SHEET TO THIS FORM.) IF ANY REAL ESTATE HAS BEEN DISTRIBUTED OR SOLD WITHIN THE FINAL TAX PERIOD, GIVE THE DATE OF RECORDING TITLE TRANSFER WITH LOCAL RECORDER OF DEEDS. DATE: E-MAIL: Signature City Title State Date ZIP Code Name of Person Making this Report American LegalNet, Inc. www.FormsWorkFlow.com Current Street Address 2 3 8 0 0 0 1 2 0 1 7
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