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

  Corporations Section 
  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 Cooperative Corporation                                                                                     AS 10.15 
 This Certificate of Withdrawal is only for a Foreign Cooperative 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  “Withdrawn” status.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: 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.
 Make checks and money orders payable to the State of Alaska or use the attached credit card payment form.
 The information you submit is a public record and will be posted online at Corporations.Alaska.Gov
Important: A foreign corporation authorized to transact business in this state may withdraw from this state upon obtaining from the 
commissioner a certificate of withdrawal. To obtain a certificate of withdrawal, the foreign corporation shall deliver to the  
commissioner an application for withdrawal. – AS 10.15.525, 10.06.778 
Upon the issuance of a certificate of withdrawal, the authority of a corporation to transact business in this state ceases.- AS 
10.15.525, 10.06.788 

PART I         Payment of Fees                                                                                      3 AAC 16.040

Required Fee:             Nonrefundable Filing Fee                                                                   $25.00 

PART II        Entity Information                                                        AS 10.15.525, 10.06.780 

Entity Name:  

Alaska Entity                                                           State or Country 
Number:                                                                 of Domicile: 

PART III  Attestations                                                                AS 10.15.525, 10.06.780, 10.06.780(2)-(4) 
By submitting this form, I am confirming:  
  The 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 Corporations.Alaska.Gov and click on Search Corporations Database. 
08-478 (Rev. 11/0 /2021)8                         F-COOP Certificate of Withdrawal                                    Page 1 of 2 

PART IV       Service of Process                                                               AS 10.15.525, 10.06.780(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:  
                         Street                            City                             State                       Zip 
Physical Address:   
                    P.O. Box or Street                     City                           State                         Zip 
Mailing Address:  

PART V        Signatures                                                                AS 10.15.525, 10.06.783, 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: Corporations.Alaska.Gov and click on Search Corporations 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 

Printed Name: 

Signature:                                                                              Date:  

Required Signature 2:    Secretary                 Assistant Secretary  

Printed Name: 

Signature:                                                                              Date: 

IMPORTANT: Remember to notify other sections of this division when appropriate: 
 Business Licensing Section: BusinessLicense.Alaska.Gov
  Submit Business License: Request to Cancel form (#08-4732) to cancel any business licenses associated with this entity.
 Professional Licensing Section:        ProfessionalLicense.Alaska.Gov
  Email License@Alaska.Gov for more information and appropriate forms.

08-478 (Rev. 11/08/2021)                           F-COOP Certificate of Withdrawal                                     Page 2 of 2 

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

  Corporations Section 
  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.

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

Entity Name:  

Alaska Entity 
Number: 

PART II       Contact Information 
Whom may we contact with any questions or problems with this filing?  

Company:   

Contact Person:  
                   P.O. Box or Street                          City                    State     Zip 
Mailing Address:  

Phone Number:                                                        Email Address:  

PART III      Document Return Address 
  Return my filings to the address provided ABOVE. 

  Return my filings to the address provided BELOW: 

Company: 

Contact Person: 
                   P.O. Box or Street                          City                    State     Zip 
Mailing Address:  

08-561 (Rev. 11/08/2021)                                      Contact Information                Page 1 of 1 

              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! 

   1.    Account Number:                                                                                      All four fields MUST 
                                                                                                                                    be completed! 
   2.    Expiration Date:
                                                                                                              This section will be 
   3.    Billing ZIP Code:
                                                                                                              destroyed after the 
   4.    Security Code:                                                                                       payment is processed.