Indiana Department of Revenue
Adavit for Reinstatement of Domestic Corporation
_________________________________________________ being duly sworn according to law, arms under penalty of
of perjury that he/she is the ___________________________________________ _______________________________
a corporation organized under the laws of the State of Indiana, , with its principal _____________________________
, county , oce located at address ____________________________________________________ ________________
, and identied by Federal Employer , ZIP, state city ________________________ _________ _______________
, and Indiana sales and/or withholding tax TID # Identication Number______________________________
_______________________________ and that he/she makes this adavit for and on behalf of this corporation. He/She
, in care states that the books and records of this corporation are kept at _______________________________________
, and that this corporation is engaged in the business ofof ________________________________________
. To the best of my belief and knowledge, all of the said corporation’s __________________________________________
Indiana taxable income received on and after May 1, 1933, has been included in Indiana income tax returns led with the
Indiana Department of Revenue and that all tax has been paid. The latest Indiana sales and/or withholding tax return were
./led for the month/year , under the name of _____ _____ __________________________________
That this adavit is made for the sole purpose of inducing the Indiana Department of Revenue, to issue a notice as
provided by the applicable taxing acts to the eect that such corporation has paid all taxes due from it under the taxing
acts which will permit the Indiana Secretary of State to reinstate the corporation to active status.
Mail to: Indiana Department of Revenue, Titles & Clearances Division, P.O. Box 6197, Indianapolis, IN 46206-6197.
(corporation name)
State Form 49514
(R5 / 4-20)
(ocial capacity)
(incorporation date)
(primary purpose)