THE  TATE S
                                                                                                                                                  COR 
                                  of                                                                                             FOR DIVISION USE ONLY 

                                       ALASKA 
  
                                 Department of Commerce, Community, and Economic Development 
                                 Division of Corporations, Business and Professional Licensing 
                                   
                                  Corporations Section 
                                  State Office Building, 333 Willoughby Avenue, 9th Floor  
                                  PO Box 110806, Juneau, AK 99811-0806 
  
                                  Phone: (907) 465-2550 • Fax: (907) 465-2974 
  
 --                               Email: corporations@alaska.gov 
                                  Website: Corporations.Alaska.Gov 
                                   
  Certificate of Withdrawal 
  
  Foreign          Nonprofit Corporation (AS 10.20) 
          •     This Certificate of Withdrawal is only for a Foreign Nonprofit Corporation. Once filed, the entity will be placed into a 
          •     “Withdrawn”     status. 
          •     This form will not be filed if the official signing this form does not match an official on record for this entity, and/or if 
                your entity’s biennial report is not current. Verify your entity’s status and current information online at: 
                 www.Corporations.Alaska.Gov, click Search Corporations  Database. 
          •     Standard processing time for complete and correct filings submitted to this office is approximately 10-15 business 
                 days (2-3 weeks). All filings are reviewed in the date order they are received. 
          •     The information you submit is a public record and will be posted online at www.Corporations.Alaska.Gov. 
 Important: A foreign corporation authorized to transact business in the state may withdraw from the state upon procuring 
 from the commissioner a certificate of withdrawal. To procure a certificate of withdrawal, the foreign corporation shall deliver 
 to the commissioner an application for withdrawal. – AS 10.20.560 
  
 Upon the issuance of a certificate of withdrawal, the authority of a corporation to transact business in this state ceases.— AS 10.20.580 
  
         PART I          Payment of Fees                                                                                             3 AAC 16.050 
                                           Non-Refundable Filing Fee                                                                             $25.00  
                 Fee:                   Mail this form and the non-refundable $25 filing fee in U.S. dollars to the letterhead address. Make the   
                                    
                                        check or money order payable to the State of Alaska, or use the attached credit card payment form.         
                                                                                                                                                          
       PART II         Entity Information                                                                                                 AS 10.20.565   

     Entity Name:                       

     Alaska Entity Number:                                        State or Country of 
                                                                       Domicile:              
  
     PART III  Attestations                                                                                         AS 10.20.565,AS              10.20.565(2)-(4) 
     By submitting this form, I am confirming: 
                
            This entity is in good standing. 
            All biennial reports due have been filed and paid.         
            The Corporation is not transacting business in Alaska.                  
              The Corporation surrenders its authority to transact business in Alaska. 
      
              The Corporation revokes the authority of the registered agent in Alaska and consents that service of process may 
            subsequently be made on the corporation by service on the Commissioner. 
       
         To verify the entity’s status and reports, go to www.Corporations.Alaska.Gov, click Search Corporations Database. 
      
 08-456            (Rev. 10/10/2020)          F-NP Certificate of Withdrawal Page 1 of 2 
  

  PART IV   Service        of Process                                                                                                                     AS 10.20.565(5) 

    Provide the name and address where the Commissioner may mail any service of process against the Corporation. 
    Per Part III, the authority of the registered agent in Alaska is revoked. Do not list the registered agent in Alaska.                                     
                                                               Entity or Individual 
   Full Legal Name: 

   Physical Address:  

   Mailing Address:  

    PART V        Required Signatures                                                                                AS 10.20.570, 10.06.825 
      
    The Certificate of Withdrawal must be signed by the President or Vice President AND the Secretary or Assistant Secretary 
    on record. If one person holds two of these titles, and there are other officers on record, then two different officers on 
    record must sign. 
     
    To verify the officers currently on record, go to: www.Corporations.Alaska.Gov, Click SearchCorporations Database.                                         
     
    Per AS 10.06.825, persons who sign documents filed with the Commissioner which are known to the person to be false in 
    material respects are guilty of a class A misdemeanor. 

   Required Signature 1:                 President               Vice President 

   Name:                                                                         
                                                                                                              
   Signature:                                                                        Date: 

    Required Signature 2:                Secretary               Assistant Secretary 

   Name:                                                                         
                                                                                                              
   Signature:                                                                        Date: 
 
Remember    to notify other sections of this division when appropriate: 
BUSINESS LICENSING SECTION:  
Submit Business License: Request to Cancel (form 08-4732) to cancel any business licenses associated with this entity.  Go to 
www.BusinessLicense.Alaska.Gov for more information and forms. 
 
PROFESSIONAL LICENSING SECTION:           
Email License@Alaska.Gov for more information and appropriate forms. 
 
08-456        (Rev. 10/10/2020)          F-NP Certificate of Withdrawal Page 2 of 2 
    

                  THE  TATE S                                                                                                                                   COR 
                     of                                                          FOR DIVISION USE ONLY 
                       ALASKA                                                                                                                 
                  Department of Commerce, Community and Economic Development 
                  Division of Corporations, Business and Professional Licensing 
 
         Corporations     Section  
                                                             th
         State Office Building, 333 Willoughby Avenue, 9  Floor 
 
         PO Box 110806,     Juneau, AK  99811-0806 
         Phone: (907) 465-2550    •Fax: (907) 465-2974 
         Email: corporations@alaska.gov       
         Website: Corporations.Alaska.Gov 

Contact Information 
 
        •  Return this form with your filing 
        •  This information may be used by the Division to assist with processing your attached filings 
        •  This form will not be filed for record, or appear online 

       Entity Information                                           Enter your entity information as it appears on this filing. 

        Entity Name:                    

        AK Entity #:                    
                                                                                                                                                                 
       Contact Person                              Whom may we contact with any questions or problems with this filing? 

        Company:                        

        Contact:                        

                                 Address: 
        Mailing Address: 
                                 City:                                                                         State:                   ZIP: 

        Phone:                      

        Email:                          
      
       Document Return Address                               Provide an address for the return of your filed documents. 
      
           Return my filings to the address provided ABOVE                       
           Return my filings to this address provided BELOW                      
      
        Company:                  

        Contact:                  

                                 Address: 
        Mailing Address: 
                                 City:                                                                         State:                   ZIP: 
 
  08-561           Rev 7/14/16           Contact Information 

              THE  TATE S                                                                                                  FOR DIVISION USE ONLY 
                of 
                  ALASKA 
              Department of Commerce, Community, and Economic Development 
              Division of Corporations, Business and Professional Licensing 

        State of Alaska 
        Department of Commerce, Community, and Economic Development 
        Division of Corporations, Business and Professional Licensing 
        PO Box 110806, Juneau, AK 99811 
        Phone: (907) 465-2550 

Credit Card Payment Form 

All major credit cards are accepted. For security purposes, do not email credit card information. 
Include this credit card payment form with your application.  

Name of Applicant or Licensee:      _________________________________________________________________________________________________________________________ 

Program Type:   ________________________________________________________       License Number (if applicable):                      ________________________________ 

 I wish to make payment by credit card for the following(check all that apply):                                                                    AMOUNT    

        Application Fee:  _________________________________________________________________________________________________                __________________________ 

        License or Renewal Fee:     _________________________________________________________________________________                      __________________________ 

        Other (name change, wall certificate, fine, duplicate license, exam, etc.):        

           1. _____________________________________________________________________________________________________________________ __________________________ 

           2. _____________________________________________________________________________________________________________________        __________________________

                                                                                               TOTAL:            ___________________________ 

Name (as shown on credit card):   ________________________________________________________________________________________________________________________ 

Mailing Address:            ___________________________________________________________________________________________________________________________________________________ 

Phone Number:   ________________________________________________________      Email (optional):               _______________________________________________________ 

Signature of Credit Card Holder:              _____________________________________________________________________________________________________________________ 

 08-4438                   Rev 12/26/18                   Credit Card Payment Form (all major cards accepted) 

   CREDIT CARD INFO:  Your payment cannot be processed unless all fields are completed! 

                                                                                                                           All  3fields            MUST 
   1. Credit Card Number:                                                                                                           be completed! 

   2. Expiration Date:                                                                                        This section will be 

      Security Code:                                                                                          destroyed after the 
   3.
                                                                                                              payment is processed.