REV-238 CM (04-13)

                                                                                                                                  DEPARTMENT USE ONLY

BUREAU OF COMPLIANCE                             OUT OF EXISTENCE/WITHDRAWAL
OUT OF EXISTENCE/MERGER SECTION
PO BOX 280947                                    AFFIDAVIT
HARRISBURG  PA 17128-0947                                 Revenue ID
             717-783-6052
TT# 800-447-3020 (Services for taxpayers
with special hearing and/or speaking needs only) PLEASE PRINT OR TYPE INFORMATION

                         THIS FORM MUST BE PROPERLY SIGNED AND NOTARIZED
NOTE:
•If filing a final RCT-101 corporate report for 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 by email that the corporation is out of business, please provide email address on reverse side.

Date of Incorporation or
Certificate of Authority                                                                                                                                                      Account ID/Revenue ID
State of Incorporation                                                                                                                                                        Entity ID (EIN)
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*                                                                                                         Month Day , and all assets wereYearsold, assigned or
distributed on                                                                                                        Month Day , and since that time,Yearthe 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 corpo-
rations 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                                , yearPlease Sign After Printing.
                                                          (Signature of Affiant)
(Notary Public, District Justice or Authorized Agent,
Department of Revenue)                           TITLE

My commission expires                                                                                                                 , year
                                                          (Present address of Affiant)

                Please Sign After Printing.      Telephone Number  (         )
                (Notary Signature and Seal)

                                                 PLEASE PRINT OR TYPE INFORMATION
                                                 NO FILING FEE

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          PRINT FORM

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                                                                                                                                                                                                                                                                                                                                     RECEIVED BY EACH STOCKHOLDER
                                                                                                                                                                                                                               AMOUNT AND NATURE OF OTHER ASSETS
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 OUNT OR VALUE RECEIVED BY EACH.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    State
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                                                                                                                                                                                                                                                                                                                                                                                                                            AMOUNT MM/DD/YY                         Code                                  Code                                  Code                                  Code                                       Code                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Signature
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                                                                                                                                                                                             MM/DD/YYYY
                                                                                                                                                                                                                                                                  STOCKHOLDER
                                                                                                                                          Revenue ID/ Corp. Box # Date of Final Distribution                                                                                                                                                                                                                                DATE             Social Security Number State          Social Security Number State          Social Security Number State          Social Security Number State          Social Security Number      State
                                                                                                                                                                                                               MONEY RECEIVED BY EACH                                                                                                                                                                                       PAR VALUE MM/DD/YY
                                                                                                                                                                                                       ZIP Code

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                                                                     OF ASSETS
DISTRIBUTION                                                                                                          Please Print or Type
                                                                                                                                                                                                                                                                OF

                                                                                                                                                                                                               SHARES OF STOCK                                                                                                                                   EACH STOCKHOLDER                                           NUMBER
                                                                                                                                                                                                                                                                                                                                                                                                                                                                    City                                  City                                  City                                  City                                       City
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                                                                                                                                                                                                       State

                                               IF THE CORPORATION HAS

                                               ONLY

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                                                                                                                                                                                                                                                                                                                                                                                  (Provide copies of Federal Form 1099-DIV)                                                                                                                                                                                                                     CORPORATIONS WITHDRAWING FROM PA BUT CONTINUING OPERATIONS OUTSIDE OF PA MUST PROVIDE THE FOLLOWING INFORMATION AND/OR DOCUME FULL DETAILS OF DISPOSITION OF PA PROPERTY. ATTACH COPIES OF FEDERAL SCHEDULE D AND/OR FEDERAL FORM 4797, IF APPLICABLE. PLEASE INDICATE IF SALES IN PA WILL CONTINUE AFTER DATE OF CESSATION. IF SO, HOW WILL THEY BE NEGOTIATED AND BY WHOM?                                                                                                                                                                                                                                                                                                                                                     (ATTACH A SEPARATE SHEET TO THIS FORM.)                                                                                                                                 (ATTACH A SEPARATE SHEET TO THIS FORM.)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 IF ANY CONSIDERATION WAS PAID FOR ANY OF THE ASSETS, STATE NAME AND ADDRESS OF INDIVIDUAL OR CORPORATION MAKING SUCH PAYMENT AN                                         IF ANY MONEY OR PROPERTY REMAINS UNDISTRIBUTED, STATE AMOUNT, NATURE AND VALUE OF SAME, AND STATE WHY IT HAS NOT BEEN DISTRIBUT                                        IF ANY REAL ESTATE HAS BEEN DISTRIBUTED OR SOLD WITHIN THE FINAL TAX PERIOD, GIVE THE DATE OF RECORDING TITLE TRANSFER WITH LOC       EMAIL:
                                                                                                                                          Name of Corporation     Business Address                     City                                                       A. CORPORATION OPERATING 100% WITHIN PA MUST COMPLETE THIS SECTION                                                                                                         Stockholder Name       Street Address Stockholder Name       Street Address Stockholder Name       Street Address Stockholder Name       Street Address Stockholder Name            Street Address B.                                                                                                                            1.                                                                                                                       2.                                                                                                                    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 AM ●                                                                                                                                                                       ●                                                                                                                                                                      ●                                                                                                                               ●           Name of Person Making this Report                       Current Street Address
THIS SCHEDULE  MUST BE COMPLETED.              ENTER “NONE”                              NO ASSETS AND/OR LIABILITIES.