C-9021
(11-19)                         State of New Jersey - Division of Taxation
         APPLICATION FOR REINSTATEMENT OF CORPORATE CHARTER

Mail To: State of New Jersey
         Department of The Treasury
         Division of Taxation
         Project Enforcement Team
         PO Box 195
         Trenton, NJ 08695-0195

Email To: Project Enforcement Team
         nj.reinstatement@treas.nj.gov

This form is to be used to permit the Director of the Division of Taxation to release information pertaining to the reinstatement of a
corporation’s charter to the authorized representatives of subject corporation.  The following information is submitted in order to
avoid inordinate delays in the reinstatement process. Please type or print clearly.

Complete Name of Corporation:________________________________________________________________________________

Trade Name (if any):_________________________________________________________________________________________

Business Address: ___________________________________________________________________________________________

         ___________________________________________________________________________________________

Corporation Serial Number:____________________________________________________________________________________

Federal Identification Number: _________________________________________________________________________________

Date and State of Incorporation: ________________________________________________________________________________

Date Charter Declared Void: ___________________________________________________________________________________

Nature of Business: __________________________________________________________________________________________

Does Corporation hold Title to Real Estate? __________   If so, when acquired? _________________________________________

Does Corporation derive income from the rental of such property? ____________________________________________________

Corporation Status (check one):        ACTIVE      INACTIVE

Permission is hereby granted to release any information regarding the above corporation necessary to facilitate the reinstatement of
the corporation’s charter to the agent named below:

______________________________________________________     ________________________________________________
Name                                                       Relationship to Corporation

__________________________________________________________________________________________________________
No.                                                        Street

__________________________________________________________________________________________________________
City                                                       State                      Zip Code

Telephone Number: (__________)___________________________
                  Area Code            Number

__________________________________________________________________________________________________________
Authorized Signature Corporate Officer                     Title                      Date