Application For Certificate Of Withdrawal (Foreign Corporation) {CF-5}

FILING FEE: $25 - Expedited service not available for this type of filing.FILE ONE ORIGINAL (Two if you want a filed stamped copy returned to you.) 1.The name of the corporation is: 2.It is incorporated under the laws of the State of: Zip Code: State: City: Address 2: Address 1: Name: Current name and addressof agent (person or entity) towhich any service of processagainst the corporation maybe mailed. Include entity/corporation name on addressline, if necessary.3.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.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.) *** In accordance with the provisions of the West Virginia Code 24731D-15-1520, the undersigned corporation *** hereby applies for a certificate of withdrawal from West Virginia, and submits the following statement: Contact Name: Phone Number: 6.Signature information (See below *Important Legal Notice Regarding Signature): Print Name of Signer: Title/Capacity: Signature: Date:5. 4. *Important Legal Notice Regarding Signature: Per West Virginia Code 24731D-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.APPLICATION FOR CERTIFICATE OF WITHDRAWAL FROM CERTIFICATE OF AUTHORITYForm CF-5 Rev. 11/2017West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.gov INSTRUCTIONS FOR FILING A CERTIFICATE OF WITHDRAWAL FROM CERTIFICATE OF AUTHORITY (In accordance with the provisions of the West Virginia Code 24731D-15-1520.)In order for the Office of the Secretary of State to issue a Certificate of Withdrawal for a foreign profit or non-profit corporation, the corporation must submit an application for withdrawal. Filing fee is $25 and you should make checks payable to the West Virginia Secretary of State. The Secretary of State will request, in writing, clearances from the following state agencies: 267 West Virginia State Tax Department, 267 Employer Coverage Unit (Workers Compensation) and 267 Department of Employment Security. When those clearances are received in writing, which may take as long as two (2) years, a Certificate of Withdrawal will be prepared and mailed to the address given on the Articles of Withdrawal. You will be held liable for all taxes, fees, penalties, interest, etc. until clearances are obtained from all departments and divisions listed above. The filing fee is $25 and the check should be made payable to the WV Secretary of State. If you are requesting a Certified Copy of the filing returned to you, include the additional payment of $15 per Certified Copy requested. =Total Fee: $15 per Certified Copy: + $25Registration fee: Make your checks payable to West Virginia Secretary of State.IF YOU NEED ADDITIONAL INFORMATION CONCERNING FILING FOR A CERTIFICATE OF WITHDRAWAL FOR YOUR CORPORATION, PLEASE CONTACT OUR OFFICE AT 304-558-8000.Due to the nature of the withdrawal process, expedited service is not available for this filing. THE FOLLOWING PROCESSING SERVICE IS AVAILABLE FOR THIS TYPE OF FILING: 1 STANDARD PROCESSING (5-10 business days) West Virginia Secretary of State Business & Licensing Division Tel: (304) 558-8000 Fax: (304) 558-8381 Website: www.wvsos.gov Filing Submission Instructions - Business DivisionSUBMIT THE COMPLETED APPLICATION WITH THE CUSTOMER ORDER REQUEST FORM TO ONE OF THE OFFICES BELOW. CHOOSE STANDARD PROCESSING SERVICE.BUSINESS SERVICE CENTERS Standard and Expedited Filings Charleston Office One-Stop Business Center 1615 Washington Street East Charleston, WV 25311 Phone: (304) 558-8000 Fax: (304) 558-8381 Hours: Mon. - Fri. 8:30a - 5:00p EST Clarksburg Office North Central WV Business Center 200 West Main Street Clarksburg, WV 26301 Phone: (304) 367-2775 Fax: (304) 627-2243 Hours: Mon. -Fri. 9:00a - 5:00p EST Martinsburg Office Eastern Panhandle Business Center 229 E. Martin Street Martinsburg, WV 25401 Phone: TBA Fax: TBA Hours: Mon. - Fri. 9:00a - 5:00p ESTIMPORTANT: READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORMS. Please follow the instructions included with the application. Failure to include any of the required information on the form may cause the filing to be rejected.All forms may be downloaded from our web site www.wvsos.gov . Rev. 6/2018 SUBMIT COMPLETED FILING TO ONE OF THE BUSINESS CENTERS BELOW: INCLUDE PAYMENT: Be sure to enclose the correct filing fee with your filing. If paying by credit card, be sure to include the e-Payment Authorization form with your filing. Your filing will be rejected if the payment is not included or if the e-Payment Authorization form is not included if paying by credit card. Standard filing fees apply.STANDARD PROCESSING requests may be submitted by: - E-mail to CorpFilings@wvsos.gov - Fax - Walk in delivery (drop off service only filed within 5-10 business days) West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.gov E-mail: CorpFilings@wvsos.gov Customer Order RequestSUBMIT THIS COMPLETED FORM WITH YOUR FILING. Order Processing Requested*: Standard Processing* Name of Entity: Return filing to: (Return Address) Contact Name: Phone: Return Delivery Options: Email or Fax options do not receive a copy via mail; must be ordered separately. Email to: Fax to: Hold for Pick Up UPS: Acct # Other (explain below): FedEx: Acct # Mail to Return Address above Order Description (include items being ordered and fee breakdown): *PLEASE NOTE: Original paperwork is kept by this office. Include a copy of the original filing ifyou want a file stamped copy returned to you at no extra charge. Certified copy requests are an additional $15 per certified copy being requested. Total Amount: Payment Method: Cash (Do Not mail cash) Pre-paid Acct #: Credit Card (Must attach e-Payment Authorization request form including payment information.) Check/Money Order(Avg. processing turnaround 5-10 business days)Rev. 11/2017*"Processing" indicates the filing will be completed and registered in the Secretary of State registration database.Attach signed pre-paid slip. e-Payment Authorization Credit Card Number: Card Type: Service Type: Fax Mail E-mail Visa Mastercard Discover American Express Payment Information Storage Authorization Year: Entity Name: Name as it appears on the account Billing Address City State Zip Code Telephone Ext.I authorize the Secretary of State to store this payment information for future payment transactions processed by Secretary of State: Authorized Signature X (required) (optional) DateThis document contains confidential financial information and will be properly shredded after payment has been processed by this office. Electronic storage of payment information is only permitted by signed author