Fillable APPLICATION FOR CERTIFICATE OF WITHDRAWAL BY REASON OF (North Carolina Secretary of State)

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APPLICATION FOR CERTIFICATE OF WITHDRAWAL BY REASON OF (North Carolina Secretary of State)

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BUSINESS REGISTRATION DIVISION P.O. BOX 29622 RALEIGH, NC 27626-0622
(Revised July 2017) (Form BE-09)
Instructions for Filing
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
BY REASON OF MERGER, CONSOLIDATION
OR CONVERSION
Item 1 Enter the name of the surviving or resulting entity in item 1. Enter the name of the State or Country (if formed
outside of the USA) of the surviving or resulting business entity in item 1(a). Enter the type of business entity of the
surviving or resulting business entity in item 1(b). e.g. Business Corporation, Limited Liability Company etc.
Item 3 Enter the name of the merging or converting entity, the name of the State or Country (if formed outside of the USA)
of the merging or converting business entity, the type of business entity of the merging or converting business entity
( e.g. Business Corporation, Limited Liability Company etc.)
Item 5 Enter the mailing address to which the Secretary of State may send a copy of any process served to us on behalf of
the merging or converting business entity.
Item 7 This document must be accompanied by a certified copy of the Articles of Merger, a Certificate of Merger, a
certified copy of the conversion documents or a Certificate of Conversion duly authenticated by the Secretary of
State or other official having custody of records of such entities in the state or country under the laws of which such
merger or conversion was effected.
Item 8 The document will be effective on the date and at the time of filing, unless a delayed date or an effective time (on
the day of filing) is specified. If a delayed effective date is specified without a time, the document will be effective
at 11:59 p.m. Raleigh, North Carolina time on the day specified. If a delayed effective date is specified with a time,
the document will be effective on the day and at the time specified. A delayed effective date may be specified up to
and including the 90
th
day after the day of filing.
Date and Execution
Enter the date the document was executed.
In the blanks provided enter:
• The name of the surviving or resulting business entity as it appears in item 1.
• The signature of the applicable representative executing the document.
• Business Corporation/Nonprofit Corporation: the document must be signed by the Chairman or any
other Officer of the Corporation.
• Limited Liability Company: the document must be signed by a Company Official of the LLC.
• Limited Partnership/Limited Liability Partnership: the document must be signed by a General Partner
of the LP/LLP.
• The name and title of the above-signed representative.
BUSINESS REGISTRATION DIVISION P.O. BOX 29622 RALEIGH, NC 27626-0622
(Revised July 2017) (Form BE-09)
State of North Carolina
Department of the Secretary of State
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
BY REASON OF MERGER, CONSOLIDATION
OR CONVERSION
Pursuant to §55-15-21, §55A-15-21, § 57D-7-21, § 59-91 or § 59-909, of the General Statutes of North Carolina
as applicable, the undersigned entity, as the surviving or resulting entity in a statutory merger, consolidation or
conversion hereby applies to the Secretary of State for a Certificate of Withdrawal for the foreign entity(ies)
authorized to transact business or conduct affairs in the State of North Carolina named below, whose separate
existence has ceased as a result of the merger, consolidation or conversion, and for that purpose submits the
following statement:
1. The name of the surviving or resulting entity is:
______________________________________________________________________________________
a. The surviving or resulting entity is incorporated, formed or created under the laws of:
____________________________________________________________________________________
b. The type of entity of the surviving or resulting entity:_________________________________________
2. The surviving or resulting entity is not authorized to transact business or conduct affairs in the State of
North Carolina.
3. The name of the merging or converted foreign entity authorized to transact business in North Carolina, its
fictitious name used in the State of North Carolina, if different from it official name, the state or country
under whose law the entity was incorporated, formed or created, and the type of entity of the foreign entity.
Official Name
Fictitious Name,
if any
State or Country
Type of Entity
4. The surviving or resulting entity hereby consents that service of process based on any cause of action arising
in the State of North Carolina, or arising out of business transacted or affairs conducted in this State during
the time each foreign entity was authorized to transact business or conduct affairs in this State may
thereafter be made by service thereof on the Secretary of State.
BUSINESS REGISTRATION DIVISION P.O. BOX 29622 RALEIGH, NC 27626-0622
(Revised July 2017) (Form BE-09)
5. The mailing address to which the Secretary of State may mail a copy of any process served pursuant to the
paragraph above is:
C/O: __________________________________________________________________________________
Address: _______________________________________________________________________________
City, State, Zip Code: ____________________________________________________________________
6. The surviving or resulting entity hereby agrees to file a statement of any subsequent change in its mailing
address with the Secretary of State.
7. Attached hereto is a copy of the articles of merger, consolidation or conversion or a certificate reciting the
facts of the merger, consolidation or conversion duly authenticated by the Secretary of State or other official
having custody of records of such entities in the state or country under the laws of which such merger was
effected.
8. This application will be effective upon filing, unless a date and/or time is specified here:_______________
This the ________day of ________________ , 20____.
____________________________________
Name of Surviving/Resulting Entity
____________________________________
Signature
____________________________________
Type or Print Name and Title
NOTES
1. Filing fee is $10. This application must be filed with the Secretary of State. The application must be accompanied by a copy of the
articles of merger, consolidation or conversion or a certificate reciting the facts of the merger, consolidation or conversion duly
authenticated by the Secretary of State or other official having custody of the records of such entities in the state or country under the
laws of which the foreign entity was organized, incorporated or created.
2. This form is to be used only if the surviving corporation is not authorized to transact business or conduct affairs in North Carolina.
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APPLICATION FOR CERTIFICATE OF WITHDRAWAL BY REASON OF (North Carolina Secretary of State)

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Completed 24 November 2020

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