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APPLICATION FOR CERTIFICATE West Virginia Secretary of State
OF WITHDRAWAL FROM Business & Licensing Division
CERTIFICATE OF AUTHORITY Tel: (304)558-8000
Form CF-5 Fax: (304)558-8381
Rev. 11/2017 Website: www.wvsos.gov
FILE ONE ORIGINAL
(Two if you want a filed stamped
copy returned to you.)
FILING FEE: $25 - Expedited service not available for this type of filing.
*** In accordance with the provisions of the West Virginia Code §31D-15-1520, the undersigned corporation ***
hereby applies for a certificate of withdrawal from West Virginia, and submits the following statement:
1. The name of the corporation is:
2. It is incorporated under the laws of the State of:
3. Current name and address Name:
of agent (person or entity) to
which any service of process Address 1:
against the corporation may
be mailed. Include entity/
Address 2:
corporation name on address
line, if necessary.
City: State: Zip Code:
4. The following statement does not apply to insurance companies who are registered and will continue to be
registered with the West Virginia Insurance Commission. The company hereby attests that it is not transacting
business in West Virginia. It hereby surrenders its authority to transact business in West Virginia. It revokes
the authority of its registered agent in West Virginia to accept service of process, and consents that service of
process in any action, suit or proceeding based upon any course of action arising in West Virginia during the
time the corporation was authorized to transact business in West Virginia may thereafter be made on the
corporation by service thereof on the Secretary of State of West Virginia and commits to notify the Secretary of
State of any changes of the corporations mailing address.
5. Name and phone number of contact person. (This is optional, however, if there is a problem with the filing,
listing a contact person and phone number may avoid having to return or reject the document.)
Contact Name: Phone Number:
6. Signature information (See below *Important Legal Notice Regarding Signature):
Print Name of Signer: Title/Capacity:
Signature: Date:
*Important Legal Notice Regarding Signature: Per West Virginia Code §31D-1-129. Penalty for signing false document.
Any person who signs a document he or she knows is false in any material respect and knows that the document is to be
delivered to the secretary of state for filing is guilty of a misdemeanor and, upon conviction thereof, shall be fined not more than
one thousand dollars or confined in the county or regional jail not more than one year, or both.
Important Note: This form is a public document. Please DO NOT provide any personal identifiable information on
this form such as social security number, bank account numbers, credit card numbers, tax identification or driver's license
numbers.
