New York State 
                                                                                        Department of State 
                                                                                        DIVISION OF CORPORATIONS, 
                                                                                        STATE RECORDS AND  
                                                                                        UNIFORM COMMERCIAL CODE 
                                                                                                                One Commerce Plaza 
                                                                                                                99 Washington Ave. 
                                                                                                                Albany, NY 12231-0001 
                                                                                                                    www.dos.ny.gov 
 
                    CERTIFICATE OF SURRENDER OF AUTHORITY 
                                     OF 
 
                                    (Insert Name of Foreign Corporation) 
                                    Under Section 1310 of the Business Corporation Law 
 
                    FIRST: The name of the corporation as it appears on the index of names in the Department of  

               State is:                                                                                                                                              .                        
                    The fictitious name the corporation has agreed to use in New York State, if applicable, is: 

                                                                                                                                                                               . 
 
                   SECOND:          The jurisdiction of incorporation is: 
 
                                                                                                                                                                               . 
                                    
                    THIRD: The date the Application of Authority was filed with the Department of State is: 
 
                                                                                                                                                                                      . 

                    FOURTH:         The corporation surrenders its authority to conduct business in New York State. 

                   FIFTH: The corporation revokes the authority of its registered agent, if any, previously designated. 

 SIXTH: The corporation consents that process against it in any action or special proceeding 
 based upon any liability or obligation incurred by it within this state before the filing of the 
 certificate of surrender of authority may be served on the Secretary of State after the filing thereof 
 
                                                                            (continued) 

 DOS-1563-f (Rev. 03/17)                                                                                             Page 1 of 2

                     in the manner set forth in paragraph (b) of Section 306 (Service of process). The address to which 
                     the Secretary of State shall mail a copy of any process against it served upon him is: 
 
                                                                                                                                           . 
 
                   X                                                 
                                         (Signature)                                   (Name of Signer) 
 
                                                                                                                       (Title of Signer) 
 
                                      CERTIFICATE OF SURRENDER OF AUTHORITY 
                                                                      OF 
                                                                                                                                          
                                                                    (Insert Name of Foreign Corporation) 
 
                                                    Under Section 1310 of the Business Corporation Law 
  
            Filer’s Name and Mailing Address: 

                          Name: 

                          Company, if Applicable: 

                          Mailing Address:

                          City, State and Zip Code: 

                     NOTES: 
                     1. The name of the corporation and the date the Application for Authority was filed must be exactly as they appear  
                           on the records of the Department of State.  This information should be verified on the Department of State’s 
                           website at www.dos.ny.gov. 
                       2. This certificate must be signed by an officer, director or duly authorized person. 
                       3. Attach the consent of the New York State Tax Commission. To request consent, call the NYS Department of  
                           Taxation and Finance at (518) 485-2639. 
                       4. The fee for filing this certificate is $60, made payable to the Department of State. 
                       5. You are not required to use this form. You may draft your own form or use forms available at legal stationery  
                           stores. The Department of State recommends that legal documents be prepared under the guidance of an attorney.     
                      
                     For Office Use Only 

 DOS-1563-f (Rev. 03/17)                                                                                                                   Page 2 of 2