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CSCL/CD-561 (Rev. 10/17)

MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
CORPORATIONS, SECURITIES & COMMERCIAL LICENSING BUREAU
Date Received (FOR BUREAU USE ONLY)
AC1

This document is effective on the date filed, unless a
subsequent effective date within 90 days after received
date is stated in the document.
Name

Address

City State ZIP Code
EFFECTIVE DATE:
Document will be returned to the name and address you enter above.
If left blank, document will be returned to the registered office.

APPLICATION FOR CERTIFICATE OF WITHDRAWAL
For use by Foreign Corporations
(Please read information and instructions on the last page)

Pursuant to the provisions of Act 284, Public Acts of 1972 (profit corporations), or Act 162, Public Acts of 1982 (nonprofit corporations),
undersigned execute the following Application:

1. The name of the corporation is:

2. The identification number assigned by the Bureau is:

3. It is incorporated under the laws of

4. The corporation is not transacting business or conducting affairs in Michigan.

5. The corporation hereby surrenders its authority to transact business or conduct affairs in Michigan.

Signed this day of ,

By
(Signature of authorized officer or agent)

(Type or Print Name)

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CSCL/CD-561 (Rev. 10/17)

Preparer's Name

Business telephone number ( )

INFORMATION AND INSTRUCTIONS
1. This form maybe used to draft your Certificate of Withdrawal. A document required or permitted to be filed under the act cannot befiled
unless it contains the minimum information required by the act. The format provided contains only the minimal informationrequired to
make the document fileable and may not meet your needs. This is a legal document and agency staff cannot provide legaladvice.
2. Submit one original of this document. Upon filing, the document will be added to the records of the Corporations, Securities &
Commercial Licensing Bureau. The original will be returned to your registered office address unless you enter a different address inthe
box on the front of this document.
Since this document will be maintained on electronic format, it is important that the filing be legible. Documents with poor black and
white contrast, or otherwise illegible, will be rejected.
3. This application is to be used pursuant to section 1031 of Act 284, P.A. of 1972 or Act 162, P.A. of 1962, for the purpose of
withdrawing a corporation's Certificate of Authority to Transact Business or Conduct Affairs in Michigan. Upon filing of this Application
a corporation surrenders its authority to conduct affairs in this state.

4. Within 60 days after submitting this certificate, all corporations must request a tax clearance from the Michigan Department ofTreasury,
Tax Clearance Section, Lansing, MI 48909, (517) 636-5260.

5. All nonprofit corporations, unless organized for religious purposes, must obtain consent to the withdrawal or a written statement that
consent is not required from the Attorney General’s Office and submit it with this document. Contact the Charitable Trust Section,
Licensing and Regulation Division, Department of Attorney General, P.O. Box 30214, Lansing, MI 48909 or phone (517) 335-7571.
Application for the consent should be made at least 120 days before the desired effective date of the withdrawal. This document cannot
be filed unless it is accompanied by either the written consent of the Attorney General or an affidavit attesting to the submission of a
written request to the Attorney General for consent to the filing and the failure of the Attorney General to respond within 120 days.
6. Item 2 - Enter the identification number assigned by the Bureau. If this number is unknown, leave it blank.
7. Profit Corporations - Complete the attached worksheet to determine if there are any unpaid fees payable.
8. The application must be signed by an authorized officer or agent of the corporation.
9. NONREFUNDABLE FEE: Make remittance payable to the State of Michigan. Include corporation name and identification number

on check or money order............................................................................................................................................................$10.00

Submit with check or money order by mail: To submit in person:

Michigan Department of Licensing and Regulatory Affairs 2501 Woodlake Circle
Corporations, Securities & Commercial Licensing Bureau Okemos, MI
Corporation sDivision Telephone: (517) 241-6470
P.O. Box 30054
Lansing, MI 48909 Fees may be paid by check, money order, VISA, MasterCard,
or Discover when delivered in person to our office.

Documents that are endorsed filed are available at www.michigan.gov/corpentitysearch. If the submitted document
is not fileable, the notice of refusal to file and document will be available at the Rejected Filings Search website at
www.michigan.gov/corprejectedsearch.

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals
with disabilities.

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IDENTIFICATION NUMBER FOREIGN PROFIT CORPORATION WORKSHEET
Changes in Shares Attributable
Occurring January 1, 2006 or later

Section A
1. Total Authorized Shares

2. Multiply by the Michigan Tax Apportionment Percentage X %
for year ending / /

3. Equals total shares attributable to Michigan =

4. Subtract previous attributable shares -

5. Equals increase in attributable shares =

If Line 5 is '0', there is no additional fee due for this worksheet. If Line 5 is greater than '0' but less than 10,000,0001, refer to the fee schedule
below in Section B. If Line 5 is 10,000,001 or greater, proceed to Section C.

Section B
Increase of 60,000 or fewer authorized shares attributable to Michigan $50.00

Increase of 60,001 - 1,000,000 authorized shares attributable to Michigan $100.00

Increase of 1,000,001 - 5,000,000 authorized shares attributable to Michigan $300.00

Increase 5,000,001 - 10,000,000 authorized shares attributable to Michigan $500.00

Section C
1. Total increase in shares attributable to Michigan from Section A, line 5.

2. Subtract 10,000,000 - 10,000,000

3. Equals increase in attributable shares in excess of 10,000,000 =

4. Divide by 10,000,000 (round any fraction to the next highest whole number)

5. Multiply by $1,000.00 X $1,000.00

6. Fee for increase in excess of 10,000,000 shares attributable =

7. Fee for increase of initial 10,000,000 shares attributable + $500.00

8. Total fee for increase in shares attributable to Michigan =

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WORKSHEET INSTRUCTIONS

Section A

Line 1. Enter the total number of authorized shares.

Line 2. Enter percentage from the corporation's Michigan tax return. If the corporation is not required to file a Michigan tax return, enter
"not required". If the business activities are confined solely to this state, 100% of the authorized shares are attributable to this state.
If you have any questions regarding tax matters, please contact the Michigan Department of Treasury by calling (517) 636-6925.

Line 3. Multiply total authorized shares from Line 1 by the percent of Line 2 for the total number of shares attributable to Michigan.

Line 4. Enter the number of shares previously attributable to Michigan. Corporations that received a Certificate of Authority after
September 30, 1989, have 60,000 shares initially attributable to this state. If you have questions regarding this information, contact
the Document Review Section at (517) 241-6470.

Line 5. Subtract Line 4 from Line 3. If number is greater than '0' and the attributable share increase on Line 5 is 10,000,000 or less, refer to
Section B for the fee. If line 5 is greater than 10,000,000 complete Section C to compute the fee.

Section B
Increase of 60,000 or fewer authorized shares attributable to Michigan $50.00
Increase of 60,001 - 1,000,000 authorized shares attributable to Michigan $100.00
Increase of 1,000,001 - 5,000,000 authorized shares attributable to Michigan $300.00
Increase of 5,000,0001 - 10,000,000 authorized shares attributable to Michigan $500.00

Add fee amount above to filing fee of the document.
Section C

Line 1. Enter the increase in attributable shares from Section a, Line 5.

Line 2. Subtract the first 10,000,000 shares from the total attributable shares in Line 1.

Line 3. Enter the increase in attributable shares over 10,000,000.

Line 4. The fee is based on increments of 10,000,000 shares. For a share of 1 to 10,000,000,000 do not divide. Write "1" on Line 4.
For an increase of 10,000,0001 or more shares, divide the number of Line 3 by 10,000,000 to determine the number of
increments. Round any fractional portions up to the next highest "whole" number.

Line 5. Multiply the "whole" number in Line 4 by $1,000.00

Line 6. The fee due on the increase of shares attributable over 10,000,000.

Line 7. the fee due for the initial increase of 10,000,000 shares attributable is $500.00.

Line 8. Add the figures from Line 6 and Line 7 together to calculate the total fee for the increase in shares attributable (add to filing fee
of the document).

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Optional expedited service.
Expedited review and filing, if fileable, is available for all documents for profit corporations, limited
liability companies, limited partnerships and nonprofit corporations.

The nonrefundable expedited service fee is in addition to the regular fees applicable to the specific
document.

Please complete a separate CSCL/CD-272 form for expedited service for each document submitted
in person or by mail.

24-hour service - $50 for formation documents and applications for certificate of authority.

24-hour service - $100 for any document concerning an existing entity.

Same day service
Same day - $100 for formation documents and applications for certificate of
authority.
Same day - $200 for any document concerning an existing entity.
Review completed on day of receipt. Document and request for same day expedited
service must be received by 1 p.m. EST OR EDT.

Two hour - $500
Review completed within two hours on day of receipt. Document and request for two hour
expedited service must be received by 3 p.m. EST OR EDT.

One hour - $1000
Review completed within one hour on day of receipt. Document and request for 1 hour
expedited service must be received by 4 p.m. EST OR EDT.

Documents submitted by mail are delivered to a remote location for receipts processing and are
then forwarded to the Corporation sDivision for review. Day of receipt for mailed expedited service
requests is the day the Corporation sDivision receives the request.

Rev. 10/17

PDF file checksum: 1285051286

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