State of Wisconsin                                                                       FILING FEE $40.00  

          DEPARTMENT OF FINANCIAL INSTITUTIONS                                                    Please check box to request         
          Division of Corporate & Consumer Services                                                Optional Expedited Service  +   $25.00 
                 
                                                    APPLICATION FOR  
FORM   124  
Mandatory                           CERTIFICATE OF WITHDRAWAL                                                                            
                                    FOREIGN NONSTOCK CORPORATION 
                                                     Sec. 181.1520, Wis. Stats. 
                                                            
1.                                                                                                , a foreign nonstock corporation 
                        (Entity Name) 
 
organized under the laws of                                       , affirms that it is not transacting business in  
 
the state of Wisconsin and hereby surrenders its authority to transact business therein. 
 
2.  The corporation consents to service of process as provided under s. 181.1510(3) and (4), Wis. Stats., in 
any civil, criminal, administrative, or investigatory proceeding based on a cause of action arising during 
the time it was authorized to transact business in Wisconsin.   
 
3.  The authority of the corporation’s registered agent to accept service of process on its behalf is:  
                
   revoked         not revoked 
 
4.  The mailing address of the corporation’s principal office: 
 
 Street Address                                                                                    PO Box 
                                                                                                    
 City                                 State/Province               Country                                         Zip/Postal Code 
                                                                                                                    
5.  The corporation agrees to notify the Department of Financial Institutions of any future change in the 
address provided above. 
 
6.  This document must be signed by a person authorized by the company: 
 
                 Signature                                                                                    Date 
 
                   Printed Name                                                                              Title 
                                    
(Optional) This document has a delayed effective date/time of: ________________________________ 
                                                                                                  (up to 90 days after received date) 
 
                                                                                                    Office Use Only 
 
DFI/CORP  /124 (R12/22)                                                                                                                               1 

Contact Information: 
       
                                                 Name 

                                               Mailing Address 

                   City                          State                        Zip Code 

                     Email Address                                            Phone Number 

INSTRUCTIONS (Refer to section 181.1520, Wis. Stats., for document content) 
                                                    
Please use BLACK ink. Submit one original to State of WI-Dept. of Financial Institutions, Box 93348, Milwaukee 
WI, 53293-0348, together with a check for the $40.00 filing fee, payable to the Department of Financial 
Institutions. (If sent by express or priority U.S. mail, please mail to State of WI-Dept. of Financial Institutions, 
Division of Corporate and Consumer Services, 4822 Madison Yards Way, 4th Fl., North Tower, Madison WI, 
53705.) If requesting optional expedited service, please check the expedited service box in the upper-right corner of 
the first page and include an additional $25.00. Filing fees are non-refundable. This document can be made 
available in alternate formats upon request to qualifying individuals with disabilities. Upon filing, the information 
in this document becomes public and might be used for purposes other than those for which it was originally 
furnished. If you have any questions, please contact the Division of Corporate & Consumer Services at 608-261-
7577 (hearing-impaired may call 711 for TTY) or by email at DFICorporations@dfi.wisconsin.gov. 
 
Item 1.  Provide the name of the foreign corporation and the name of the jurisdiction (either a state other than 
Wisconsin or a foreign country) under whose laws it is incorporated. 
 
Item 2.  Section 181.1520(2)(c), Wis. Stats, requires a withdrawing foreign nonstock corporation to consent to 
service of process in any civil, criminal, administrative, or investigative proceeding based on a cause of action 
arising during the time the company was registered to do business in Wisconsin.  The manner of authorized service 
is set forth in s. 181.1510(4), Wis. Stats. 
 
Item 3.  Specify whether the corporation revokes the authority of its registered agent in Wisconsin to accept service 
on its behalf.  If the authority of the registered agent is revoked, service of process may be made upon the 
corporation as provided in s. 181.1510(4). 
 
Item 4.  Provide the mailing address of the corporation’s principal office.   
 
Item 5.  Section 181.1520(2)(e), Wis. Stats., requires a withdrawing corporation to commit to notifying the 
Department of any change to the address provided in item 4. 
 
Item 6.  The document must be executed by one or more persons authorized by the company. 
 
Optional delayed effective date/time.  This document may declare a delayed effective date and time.  The 
effective date/time may not be before, or more than 90 days after, the document is received by the Department of 
Financial Institutions for filing.  If no effective date/time is specified, the document will take effect at the close of 
business on the date it is received for filing by the Department. 
 
DFI/CORP/124 (R12/22)                                                                                                     2