PDF document

- 1 -

!
State of Rhode Island This legal document
Department of State - Business Services Division should be typed.
All illegible
documents
Instructions for Filing will be REJECTED.
Application for Certificate of Withdrawal for a Foreign Non-Profit Corporation
Section 7-6-83 of the General Laws of Rhode Island, 1956, as amended
The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant statutory provision.
This form and the information provided are not substitutes for the advice and services of an attorney and/or tax specialist.

All filings are public records under RIGL 38-2-1, et seq. This means all information is available to the public by a variety of methods
including, without limitations, inspections at our office, telephone inquiries and electronically through our online database.

How to complete the form: How to pay the filing fee:

1. List the corporation’s ID number. The ID number can The filing fee is payable either by mail via check made
be found by looking up your entity in the Corporate payable to RI Department of State or in person via cash,
Database. credit card, or check at the Business Services Division, 148
W. River Street, Ste. 1, Providence, RI 02904. Contact our
2. List the name of the corporation. The entity name can be office at (401) 222-3040 for further information.
verified through the Corporate Database.
3. List the state of formation under whose laws the How to confirm your filing:
company is incorporated.
Entity records are retrievable and viewable through our
4. The corporation is not trasacting business in this state
website. Successful filings will NOT result in a mailed
and surrenders its authority to transact business in this
confirmation. Filings that cannot be processed will be posted
state.
online and then returned. To confirm your submission and
5. The Department of State will receive future service of obtain evidence of your filing:
process for the non-profit corporation regarding the
• Go to our Corporate Database.
transaction of business in Rhode Island.
• Enter the name or ID number of your entity and click
6. List the address where the Department of State may “Search.”
mail a copy of service of process against the corporation • Click on the link to your entity record, scroll down,
received by the Department of State. select “All Filings” and then “View Filing.”
7. The President OR Vice President AND the Secretary OR • Identify the desired type of filing and click on “PDF”
Assistant Secretary MUST sign and date the form. under “View PDF” to view and print the record.

FORM 254 - Revised: 12/2023

- 2 -

        State of Rhode Island
        Department of State - Business Services Division

Certificate of Withdrawal                                                                            STAMP
FOREIGN Non-Profit Corporation                                                                       FOR
                                                                                                     SECRETARY OF STATE 
                                                                                                     USE ONLY
        Filing Fee:  $10.00 

Pursuant to the provisions of RIGL 7-6-83, the undersigned foreign non-profit corporation hereby
applies for a Certificate of Withdrawal from the state of Rhode Island, and for that purpose submits 
the following statement:
1. Entity ID Number:              2. The name of the corporation is: 

3. It is incorporated                                     4. The corporation is not trasacting business in this state and 
under the laws of:                                        surrenders its authority to transact business in this state.

5. It revokes the authority of its agent to accept service of process and consents that service of process in any action, suit 
or proceeding arising out of the transaction of business in the state of Rhode Island, may thereafter be made on the non-
profit corporation by service thereof on the Department of State of the State of Rhode Island.
6. The post office address to which the Department of State may mail a copy of any process against the corporation that is 
served on the Department of State:

Under penalty of perjury, we declare and affirm that we have examined this Application for Certificate of Withdrawal, and 
that all statements contained herein are true and correct.
Type or Print the Name of       President or      Vice President                              Date

Signature of President or Vice President

Type or Print the Name of       Secretary or      Assistant Secretary                         Date

Signature of Secretary or Assistant Secretary

TWO SIGNATURES ARE REQUIRED

MAIL TO:
Division of Business Services
148 W. River Street, Providence, Rhode Island 02904-2615
Phone: (401) 222-3040                                                                                STAMP
Website: www.sos.ri.gov                                                                              FOR
                                                                                                     SECRETARY OF STATE 
                                                                                                     USE ONLY

If you have any questions, please call us at (401) 222-3040, Monday through Friday, 
between 8:30 a.m. and 4:30 p.m., or email corporations@sos.ri.gov.
                                                                                                     FORM 254 - Revised:  12/2023

- 3 -

        State of Rhode Island
        Department of State - Business Services Division

Filer Contact Information
        
In the event our office needs more information in order to complete the filing of this document, we ask for the 
filer’s contact information. All fields are REQUIRED.

Name:                                                                               Date:

Entity Name:

Street Address:

City:                                                State:                         Zip Code:

Email Address:                                                                      Phone Number: 

                                                                                         VOLUNTARY 
                                                                                         DISSOLUTION

If you have any questions, please call us at (401) 222-3040, Monday through Friday, 
between 8:30 a.m. and 4:30 p.m., or email corporations@sos.ri.gov.
                                                                                         FORM 254 - Revised:  12/2023

PDF file checksum: 174660159

(Plugin #1/9.12/13.0)