C-124 Rev. 3/96 
                                             
                                    New Jersey Division of Revenue 

                          Application for Certificate of Withdrawal 
                (For Use by Foreign Profit and Non-profit Corporations) 
                                             
Check Appropriate Statute: 
 
 __ Title 14A:13-8         New Jersey Business Corporation Act           (File in Duplicate) 
 __ Title 15A:13-8         New Jersey Nonprofit Corporation Act           (File in Triplicate) 
  
Pursuant to the provisions of the appropriate New Jersey Statute checked above, the undersigned 
corporation hereby applies for a Certificate of Withdrawal from the State of New Jersey and for this 
purpose submits the following application: 
 
1.  Name of Corporation: 
 
2.  Corporation Number: 
 
3.  Incorporated under the laws of: 
 
4.  The corporation in not transacting business activities in New Jersey. 
 
5.  The corporation hereby surrenders its authority to transact business activities in New Jersey. 
 
6.  The address to which the Treasurer, State of New Jersey may mail a copy of any process against the 
 Corporation that may be served is: 
 
 (Street and postal designation) 
  
 (City)                                    (State)                                             (Zip Code) 
  
NOTE:  Foreign Profit Corporations must attach a "Tax Clearance Certificate" from the Division of 
  Taxation, Department of Treasury, PO Box 269, Trenton, NJ 08625-0269. 
 
Signature:                                                                        Date:
                     (Must be Chairman of the Board, President or Vice President) 
 
Type Name and Title:                                                               
 
                          NJ Division of Revenue, PO Box 308, Trenton, NJ  08646

Rev  /7 11 5/0  
 
                                Instructions for Form C-124 
                             CERTIFICATE OF WITHDRAW 
                   FOREIGN PROFIT and NON- PROFIT CORPORATIONS 
                                      (Titles 14A AND 15A) 
                                         
Effective July 1, 2003, new procedures for profit corporations were implemented.  Form  
C-124P will replace this form when a foreign profit corporation initially files a combined 
dissolution/withdrawal package. 
 
STATUTORY FEE:  $75 for NON-PROFITS / $95 FOR-PROFITS ($75 Certificate fee plus 
                    $20 Tax Clearance Filing Fee) 
The MANDATORY fields are: 
 
Statutory Authority 
    Check the appropriate statutory authority (14A:13-8 and 15A:13-8). 
     
Field # 1 -- Business Name 
    List the name as it appears on the records of the State Treasurer. 
     
Field # 3 Home Jurisdiction 
    List the state of incorporation. 
     
Field # 6 -- Service of Process Address 
    Provide an address to which the Treasurer may mail any service of process. 
     
ATTESTATIONS 
    Provide a statement indicating that the corporation is withdrawing and surrenders its 
    authority to transact business activities in New Jersey. Form C-124 provides this statement. 
 
TAX CLEARANCE (For-Profit Corporations) 
    Obtain and attach to your filing submission a Tax Clearance Certificate. The 
    application form for the Tax Clearance Certificate is available online.  Remember that there 
    is a $25.00 fee for the Tax Clearance Certificate, and that the New Jersey Division of 
    Taxation issues them. 
     
    Note:  See new procedures effective July 1, 2003 for domestic and foreign profit 
    corporations. 
     
EXECUTION (DATE/SIGNATURE) 
    Have the chairman, president or vice-president sign. Also, list the date of execution 
    (signature). 
                                     * * * * * * * * * * 
 
These documents should be filed in duplicate.  Non-profits should file in triplicate. 
All annual report obligations should be satisfied prior to submitting the dissolution paperwork. 
 
Make checks payable to:  TREASURER, STATE OF NEW JERSEY.   (No cash, please) 
 
Mail to:  NJ Division of Revenue, PO Box 308, Trenton, NJ  08646