ohioPrescribed by J. Kenneth Blackwell Ohio Secretary of StateExpedite this Form: (Select One) Mail Form to one of the Following:PO Box 1390 Columbus, OH 43216Central Ohio: (614) 466-3910 Toll Free: 1-877-SOS-FILE (1-877-767-3453)Yes*** Requires an additional fee of $100 ***PO Box 1028 Columbus, OH 43216Nowww.state.oh.us/sos e-mail: busserv@sos.state.oh.usCERTIFICATE OF SURRENDER OFFiling Fee $50.00 FOREIGN LICENSED CORPORATION (For Foreign, Profit or Non-Profit )(1)Foreign For Profit(2)Foreign Non-Profit(143-SUR)(143-SUR)To the Secretary of State Columbus, Ohio FIRST: (Ohio License No.), a corporation incorporated under the laws of the State ofheretofore authorized to do business in the State of Ohio, desiring to surrender its license to do so, hereby certifies:SECOND: That it hereby surrenders its license to do business in the State of Ohio. THIRD: That the address to which the Secretary of State of Ohio may mail any process against it that may be served upon him and other notices, certificates or statements, is:(street)NOTE: P.O. Box Addresses are NOT acceptable.(state)(city, township, or village)(zip code)IN WITNESS WHEREOF, said corporation has caused this certificate to be executed by its officer duly authorized, on(date)Signature:Name:(NOTE: May be signed by president, vice-president, secretary or treasurer of the corporation, or by receiver, trustee in bankruptcy or other liquidator of such corporation.)American LegalNet, Inc. www.USCourtForms.comLast Revised: May 2002Page 1 of 5564AFFIDAVIT BY A FOREIGN CORPORATIONIn lieu of surrender releases from various governmental authorities (ยง 1703.17(D) ORC)The undersigned, being first duly sworn, declares that on the dates indicated below, each of the named state governmental agencies was advised IN WRITING of the scheduled date of filing of the Certificate of Surrender and was advised IN WRITING of the acknowledgement by the corporation that the surrender of its license does not release it of liability, if any, for payment of taxes and contributions due.AGENCYDATE NOTIFIED1. Ohio Department of Taxation Dissolution Section Box 182382 Columbus, Ohio 43218-2382 2. Ohio Job & Family Services Status and Liability Section Data Correspondence Control 4300 Kimberly Parkway Columbus Oh 43232 (614) 466-2319 3. The treasurer of any County named below:(Note: This affidavit must be signed by one or more persons executing the certificate of surrender or by an officer of the corporation.)SignatureTitleName(Street)NOTE: P.O. Box Addresses are NOT acceptable.(State)(City)(Zip)Sworn to before me and subscribed in my presence on(date)(Notary Public)Commission ExpiresSEALAmerican LegalNet, Inc. www.USCourtForms.comLast Revised: May 2002Page 2 of 5564AFFIDAVIT OF PERSONAL PROPERTYSTATE OF OHIO COUNTY OF::SS, being first duly sworn, deposes and says that she/he isof, that this(title)of the ORC;affidavit is made in compliance with section(Section #)That said corporation has: (choose one of the following)A. has no personal property in any county in the State of Ohio:B. personal property only in the following county(ies),,,and that the net assets of said corporation are sufficient to pay all personal property taxes accrued to date.Signature:Name:Sworn before me and subscribed in my presence on(date)(Notary Public)(Notary Seal)Commission expires(date)American LegalNet, Inc. www.USCourtForms.comLast Revised: May 2002Page 3 of 5564Instructions1.The EXACT name of the corporation must appear in item FIRST of the Certificate of Surrender. The name must appear as it does on the records of the Secretary of State. The name of the state under the laws of which the corporation was incorporated is to appear in the Certificate of Surrender (in the space provided on the prescribed form). For example, if the corporation was incorporated in Delaware, 'Delaware' must be inserted. A statement that the corporation is surrendering its license to transact business in Ohio. If using the form Prescribed by the Secretary of State, the statement is included in item SECOND . The address to which the Secretary of State may mail any process against the corporation that may be served upon him, and may mail any other notices, certificates or statements, must be set forth in the Certificate of Surrender in item THIRD . The Certificate of Surrender must be signed by the President, Vice President, Secretary or Treasurer or by the receiver, trustee in bankruptcy, or other liquidator of such corporation.2.3.4.5.6. Each corporation that files a Certificate of Surrender with the Ohio Secretary of State seeking to surrender its license to transact business in Ohio, is required to file an Affidavit of Personal Property. The Affidavit of Personal Property must be signed by one or more of the persons who signed the Certificate of Surrender, and must state the counties in Ohio, if any, in which the corporation has personal property, or a statement that the corporation is of a type required to pay personal property taxes to state authorities only. The affidavit must be submitted with the Certificate of Surrender. 7.(a) The Affidavit of Personal Property must be notarized by a notary public. In addition to the affidavit of personal property, each corporation that files a Certificate of Surrender with the Ohio Secretary of State seeking to surrender its license to transact business in Ohio, is required to file releases and/or certificates from each of the following governmental agencies evidence that the corporation has paid various specified taxes or contributions, or has made adequate provision thereof. Two alternative methods are provided to fulfill this requirement. (a) The Certificate Method -under this method, a corporation must obtain the following:(1)A Tax Clearance Certificate (Ohio Department of Taxation Form D-2) signed by the Tax Commissioner of Ohio which states that all franchise, sales, use and highway taxes due through the date of filing the dissolution have been paid, or that such payment has been adequately guaranteed.(A)In order to receive a Tax Clearance Certificate from the Department of Taxation, the corporation must complete Ohio Department of Taxation Form D-5 entitled Notification of Dissolution or Surrender.(2)A personal property tax release must be obtained from the County Treasurer of each county in which the corporation has taxable personal property, or if the corporation is required to pay personal property taxes to the Treasurer of State, the cor
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