Secretary of State 
                                                                Business Programs Division 
                                                                            Business Entities 
                                                   1500 11th Street, Sacramento, CA 95814 
                                               P.O. Box 944260, Sacramento, CA 94244-2600 

                                                   Submission Cover Sheet

For faster service, file online at bizfileOnline.sos.ca.gov               . 

Instructions: 

• Complete and include this form with your paper submission. This information only will be
  used to communicate in writing about the submission, if needed. This form will be
  treated as correspondence and will not be made part of the filed document.

• Make all checks or money orders payable to the Secretary of State.

• In person submissions (excluding Statements of Information): $15 handling fee; do not include
  a $15 handling fee when submitting documents by mail.

• Standard processing time for submissions to this office is approximately 5 business days from
  receipt. All submissions are reviewed in the date order of receipt with online submissions
  given priority. For updated processing time information, visit
  www.sos.ca.gov/business/be/processing-dates.

Optional Copy and Certification Fees: 

• If applicable, include optional certification fees with your submission.

• For applicable certification fee information, refer to the instructions of the specific form you are
  submitting.

Contact Person: (Please type or print legibly) 

First Name:                                      Last Name: 

Phone (optional):  

Entity Information: (Please type or print legibly) 

Name:  

Entity Number (if applicable):  

Address: 

Comments

Submission Cover Sheet (REV 03/2022)                            Clear Form  Print Form

                   Secretary of State                                         SURC
                   Certificate of Surrender 
                   (Foreign Qualified Corporation ONLY) 

There is No Fee for filing a Certificate of Surrender 

Certification Fee (Optional) –   $5.00

Note: For information about Franchise Tax Board final tax return 
requirements, go to ftb.ca.gov. 
                                                                                                 This Space For Office Use Only 

                               (Enter the exact name of the corporation as it is recorded with the California Secretary of State.   Note:  If you 
1. Corporate Name              registered in California using an assumed name.) 

2. Secretary of State         Entity Number                      3. Jurisdiction (State, foreign country or place where this corporation is formed.)

4. Mailing Address to mail copies of Legal Service (Enter the complete mailing address where the California Secretary of State may
     forward copies of any legal documents against the corporation that are served on the Secretary of State intended for the corporation.)
Mailing Address of Corporation                                           City (no abbreviations)                  State      Zip Code 

5. Required Statements (Do not alter the Required Statements – ALL must be true to file this Certificate of Surrender.)

Statements 5(a) – 5(d) are true: 
   a) The corporation surrenders its rights and authority to transact intrastate business in the State of 
      California.
   b) The corporation revokes its designation of agent for service of process in California.
   c) The corporation consents to process against it in any action upon any liability or obligation incurred
      within the State of California prior to the filing of this Certificate of Surrender may be served upon the
      California Secretary of State.
   d) All final returns required under the California Revenue and Taxation Code have been or will be filed
      with the California Franchise Tax Board.

6. Read and Sign Below         (Office or title not required. )

I am a corporate officer and am authorized to sign on behalf of the foreign corporation. 

  __________________________________________________________                    ____________________________________________________ 
Signature                                                                        Type or Print Name

SURC (REV 03/2022)                                                                                                20 22California Secretary of State  
                                                        Clear Form       Print Form                                          bizfileOnline.sos.ca.gov