Statement Under Section 1703.17 {592}

Page 1 of 3Form 592Last Revised: 06/2019 Toll Free: 877.767.3453 | Central Ohio: 614.466.3910 OhioSoS.gov | business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Filing Form Cover LetterPlease return the approval certificate to: Address: City: ZIP Code: Phone Number: E-mail Address: Check here if you would like to receive important notices via e-mail from the Ohio Secretary of State's office regarding Business Services. Check here if you would like to be signed up for our Filing Notification System for the business entity being created or updated by filing this form. This is a free service provided to notify you via e-mail when any document is filed on your business record. Please make checks or money orders payable to: "Ohio Secretary of State" Type of Service Being Requested: (PLEASE CHECK ONE BOX BELOW) Regular Service: Only the filing fee listed on page one of the form is required and the filing will be processed in approximately 3-7 business days. The processing time may vary based on the volume of filings received by our office. Expedite Service 1: By including an Expedite fee of $100.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 2 business days after it is received by our office. Expedite Service 2: By including an Expedite fee of $200.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 1 business day after it is received by our office. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Expedite Service 3: By including an Expedite fee of $300.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 4 hours after it is received by our office, if received by 1:00 p.m. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Preclearance Filing: A filing form, to be submitted at a later date for processing, may be submitted to be examined for the purpose of advising as to the acceptability of the proposed filing for a fee of $50.00. The Preclearance will be complete within 1-2 business days. Name (Individual or Business Name): To the Attention of (if necessary): State American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3Form 592Last Revised: 06/2019Toll Free: 877.767.3453 Central Ohio: 614.466.3910 OhioSoS.gov business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Mail this form to one of the following: Regular Filing (non expedite) P.O. Box 1329 Columbus, OH 43216 Expedite Filing (Two business day processing time. Requires an additional $100.00) P.O. Box 1390 Columbus, OH 43216 Statement Under Section 1703.17 (For Foreign, Profit or Nonprofit) (999-SUD or 999-SUC) Filing Fee: $50.00 Form Must Be Typed Pursuant to the provisions of Section 1703.17 of the Revised Code of Ohio, , a Name of Corporation Ohio License No. corporation organized under the laws of states that the address to which the Secretary of State may mail any process against such corporation that may be served upon him, and may mail any other notices, certificates, or statements is Mailing Address City ZIP Code Signature Name Title NOTE: This form must accompany a certificate from the corporation's jurisdiction of formation which reflects that the entity dissolved or its corporate existence otherwise terminated or a certified copy of a court order terminating the existence of the corporation. Jurisdiction of Formation State For screen readers, follow instructions located at this path.Form 592 Prescribed by: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3Form 592Last Revised: 06/2019Instruction for Statement Under 1703.17This form should be used if you wish to surrender your license pursuant to ORC 1703.17 (E). Although ORC 1703.17(B) describes the Certificate of Surrender (Form 564) which may be filed with the secretary of state, the law also provides an alternative method. ORC 1703.17(E) states a corporation may, in lieu of filing a Certificate of Surrender (Form 564), may file a certificate from the jurisdiction of formation certifying the dissolution of the corporation, or that the corporation's existence was otherwise terminated, or a certified copy of an order of court terminating the existence of the corporation. The law requires the corporation to provide the address to which the secretary of state may mail any process against such corporation that may be served upon the secretary of state, and may mail any other notices, certificates, or statements. American LegalNet, Inc. www.FormsWorkFlow.com