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                APPLICATION FOR REINSTATEMENT                                                                   SECRETARY OF STATE 
                                                                                                               BUSINESS SERVICES DIVISION 
                DOMESTIC OR FOREIGN ENTITIES                                                         302 West Washington Street, Room E018 
                State Form 4160 (R18 / 6-19)                                                                    Indianapolis, IN 46204 
                                                                                                               Telephone: (317) 232-6576 
                                                                                                                www.sos.in.gov  
INSTRUCTIONS:  1. Use 8½” x 11” white paper for attachments. 
    2. Please   or         TYPE PRINT in INK.  
                   3. Please visit our office on the web at www.sos.IN.gov 
                   4. Make check or money order payable to the Secretary of State.  
                   5. Submit original completed paperwork and payment to: 302 West Washington Street, Room E-018, Indianapolis, IN 46204. 
                   6. The Application for Reinstatement must include the following: 
                          Certificate of Clearance issued by the Indiana Department of Revenue 
                          Business Entities Reports for all outstanding years due 
                   7.  A Series cannot apply for reinstatement for the Master LLC. The Application for Reinstatement must be submitted  
                       by the Master LLC. 
                   8. Before submitting this form, please visit www.INBiz.in.gov to check if the business name is still available. If the business name is  
                       not available, please submit Articles of Amendment with this filing to change the name. 
 
NOTE:   This application for reinstatement cannot be accepted without a Certificate of Clearance for reinstatement from the  
        Indiana Department of Revenue.  
 
NOTE:   This application must be submitted within five (5) years of the effective date of the administrative dissolution. 
 
                INFORMATION CONTAINED ON THIS PAGE IS NOT PART OF THE PUBLIC RECORD. 
 
Name of business 
 
E-mail address of business (SOS use only) 
 
RETURN DOCUMENTS TO: 
 
Name 
 
Street address, line 1 
 
Street address, line 2 
 
City                                                            State                                          ZIP code 
                                                                                                                
Telephone number                             E-mail address (If different from above – SOS use only) 
                                              
(     )                                            
 

            APPLICATION FOR REINSTATEMENT 
            DOMESTIC OR FOREIGN ENTITIES 
            State Form 4160 (R18 / 6-19) 
            
                                                                                                                                                 23-0.5-6-3 
                                                                                                                                                           
                                                                                                                                   $30.00 
 
                                                     SECTION I – ENTITY INFORMATION 
Name of entity at the time of its administrative dissolution or revocation in Indiana 
      
For foreign entities only: Legal name in domicile state, if different from above 
      
Address of principal office (number and street, city, state, and ZIP code) 
      
Date of incorporation or organization / registration (month, day, year)               Effective date of administrative dissolution or revocation (month, day, year) 
                                                                                            
Please check the reason why the entity was administratively dissolved or revoked. 
   Failure to pay Business Entity Reports 
   You must include Business Entity Reports and payment for all years. 
   Failure to maintain a Registered Agent 
   Failure to notify the Secretary of State of change of Registered Agent or registered office information 
 
   SECTION II – REGISTERED AGENT INFORMATION (Do not complete if dissolved / revoked for failure to file Business Entity Reports.) 
To determine if your Registered Agent is a Commercial Registered Agent (CRA), go to INBIZ.in.gov.  
Provide either commercial registered agent or noncommercial registered agent information below. 
                                    Name of registered agent (Do not provide address.) 
  Commercial registered agent             
OR 
                                    Name of registered agent 
  Noncommercial registered agent          
Address (number and street) (A P.O. Box is not acceptable unless accompanied by a Rural Route number.) City               State                  ZIP code 
                                                                                                                          IN                           
(OPTIONAL) E-mail address of the registered agent at which the registered agent will accept electronic service of process 
      
   By checking the box, the Signator(s) represent(s) that the Registered Agent named in this Application for Reinstatement has consented to the  
   appointment of Registered Agent. 
 
                                                                          SECTION III - AFFIDAVIT 
The undersigned, being at least one of the governing persons of the above-named entity states the following: 
 
   A.     that the grounds for dissolution did not exist or have been cured, and; 
           
   B.     that the entity's name satisfies the requirements of Indiana Code 23-0.5-3-1. 

In Witness Whereof, the undersigned duly authorized representative of said entity, executes this application and verifies, subject to penalties of perjury,  
 
that the statements contained herein are true, this ______ day of ________________________, 20______. 

Signature                                                                             Printed name