APPLICATION FOR CERTIFICATE OF WITHDRAWAL FOR 
                        ALIEN BUSINESS ORGANIZATION 
                                          
                                         (Name of Alien Business Organization) 
                                          
                                         (Incorporated or Organized Under Laws of) 
                                          
This entity is no longer required to maintain a registered agent in this state. 
 
(Signature of Officer or Director) 
 
(Typed or Printed Name) 
 
(Capacity of Person Signing Application) 
 
Filing Fee: $35.00 
Certified Copy (Optional): $52.50 
 
INHS069(10/03)