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              State of Utah                                                                                                Entity Number: ________________ 
              DEPARTMENT OF COMMERCE 
              Division of Corporations & Commercial Code                                                                   [   ]  Profit Corporation 
                                                                                                                 Print
              Application   for Withdrawal                                                                                 [   ]  Non-Profit Corporation 
                                                                                                                 Clear Form

SPECIAL NOTE: Utah law requires corporations seeking withdrawal to submit a                                                Tax Clearance Certificate with 
the Application for Withdrawal.  Please inquire with the Utah State Tax Commission at 210 N 1950 W Salt Lake 
City, Utah 84134. Phone: (801) 297-2200 or Toll Free: (800) 662-4335.   

Pursuant to the provisions of Utah Law, the undersigned corporation hereby submits this Application for 
Withdraw from the State of Utah, and for that purpose submits the following statement: 

First:        Corporation Name is ___________________________________________________________________    

Second:       It is incorporated under the laws of the state of  ______________________________________________ 

Third:        It is no longer transacting business in Utah. 

Fourth:       It hereby surrenders its authority to transact business in Utah. 

Fifth:        Service of process in any action, suit or proceeding based upon any cause of action arising in Utah during 
              the time the corporation was authorized to transact business in Utah may thereafter be made on the 
              corporation by service thereof on the (check one): 

       [    ] Registered Agent of Record  (For Profit Corporations Only) 
              Name_______________________________________________________________________________

              Address___________________________________ City ________________ State ____ Zip__________ 
                         (Utah Street Address Required, PO Boxes can be listed after the street address) 

       [    ] The Principal Office 

              Address___________________________________ City ________________ State ____ Zip__________ 

Under penalties of perjury, I declare that this Application for Withdrawal, and the accompanying Tax Clearance 
Certificate, has been examined by me and is, to the best of my knowledge and belief, true, correct and complete.  

              Dated this ____________ day of ______________________________________ , 20_______ 
By: ________________________________________________   Authorized party must sign here after the form is printed Title: __________________________________ 

If the filer requests a copy of the Application for Withdrawal an additional exact copy of the filed document 
along with a return-addressed envelope with adequate first-class postage must also be submitted. 
Under GRAMA {63G-2-201}, all registration information maintained by the Division is classified as public record.  For confidentiality purposes, 
you may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity. 

Mailing/Faxing Information: www.corporations.utah.gov/contactus.html                                             Division's website: www.corporations.utah.gov

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