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                STATEMENT OF WITHDRAWAL OF                                                                SECRETARY OF STATE 
                A FOREIGN ENTITY                                                                         BUSINESS SERVICES DIVISION 
                State Form 56374 (8-17)                                                                  302 West Washington Street, Room E018 
                Approved by State Board of Accounts, 2017                                                 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. 
 
NOTE:   This form may be used by a foreign entity that wishes to withdraw its registration to do business in Indiana. 
 
                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) 
                                                  
(     )                                                
 

                STATEMENT OF WITHDRAWAL OF 
                A FOREIGN ENTITY 
                State Form 56374 (8-17) 
                Approved by State Board of Accounts, 2017 
                
The undersigned, desiring to withdraw a foreign entity from the records of the Secretary of State pursuant to the provisions of Indiana Code 23-0.5-5-7, 
executes the following Statement of Withdrawal. 
 
                                                    ARTICLE I – REASON FOR WITHDRAWAL 
Reason for withdrawal (choose one): 
    The business will remain active in its jurisdiction of formation, but wishes to withdrawal its registration to do business in Indiana. 
    The business has dissolved in its jurisdiction of formation. 
    The business has converted to a domestic or foreign entity that is not a filing entity. 
 
                                                                   ARTICLE II – ENTITY INFORMATION 
The name of the entity 
      
The jurisdiction of formation of the entity 
      
The date the foreign entity registered with the Secretary of State (month, day, year) 
      
                            ARTICLE III – BUSINESS TO REMAIN ACTIVE IN ITS JURISDICTION OF FORMATION 
                                            (Please complete this Article if you selected the first box in Article I above.) 
 
By filing this Statement of Withdrawal, the foreign entity states that it is no longer doing business in Indiana and withdraws its registration to do business 
in Indiana. 
By filing this Statement of Withdrawal, the foreign entity revokes the authority of its registered agent to accept service on its behalf in Indiana. 
By filing this Statement of Withdrawal, the foreign entity hereby commits to notify the Secretary of State in the future of any change in the foreign entity's 
mailing or e-mail address. 
If the foreign entity filing this Statement of Withdrawal is a Foreign Master LLC, the withdrawal of the Master LLC will cause the withdrawal of every 
associated  Series. 
Provide a mailing address and e-mail address to which service of process may be delivered. 
Number and street                                                                      City                        State                    ZIP code 
                                                                                                                                                  
E-mail address  
      
                ARTICLE IV – BUSINESS HAS CONVERTED TO A DOMESTIC OR FOREIGN ENTITY THAT IS NOT A FILING ENTITY 
                                    (Please complete this Article if you selected the third box in Article I above.) 
By filing this Statement of Withdrawal, the foreign entity surrenders its registration to do business in Indiana and revokes the authority of its registered 
agent to accept service on its behalf. 
Type of entity, other than a filing entity, to which the entity has converted 

Provide a mailing address or e-mail address to which service of process may be delivered. 
Number and street                                                                      City                        State                    ZIP code 
                                                                                                                                                  
E-mail address  
      
In Witness Whereof, the undersigned duly authorized representative of the foreign entity executes this Statement of Withdrawal and verifies, subject  
 
to penalties of perjury, that the statements contained herein are true, this ______ day of ________________________, 20______. 
Signature 

Printed name                                                                           Title