SPECIAL NOTE: Utah law requires corporations seeking withdrawal to submit a Tax Clearance Certificate with
the Application for Withdrawal. Please inquire with the Utah State Tax Commission at 210 N 1950 W Salt Lake
City, Utah 84134. Phone: (801) 297-2200 or Toll Free: (800) 662-4335.
Pursuant to the provisions of Utah Law, the undersigned corporation hereby submits this Application for
Withdraw from the State of Utah, and for that purpose submits the following statement:
First: Corporation Name is ___________________________________________________________________
Second: It is incorporated under the laws of the state of ______________________________________________
Third: It is no longer transacting business in Utah.
Fourth: It hereby surrenders its authority to transact business in Utah.
Fifth: Service of process in any action, suit or proceeding based upon any cause of action arising in Utah during
the time the corporation was authorized to transact business in Utah may thereafter be made on the
corporation by service thereof on the (check one):
[ ] Registered Agent of Record (For Profit Corporations Only)
Name_______________________________________________________________________________
Address___________________________________ City ________________ State ____ Zip__________
(Utah Street Address Required, PO Boxes can be listed after the street address)
[ ] The Principal Office
Address___________________________________ City ________________ State ____ Zip__________
(Street Address Required, PO Boxes can be listed after the street address)
Under penalties of perjury, I declare that this Application for Withdrawal, and the accompanying Tax Clearance
Certificate, has been examined by me and is, to the best of my knowledge and belief, true, correct and complete.
Dated this ____________ day of _______
_______________________________ , 20_______
By: ________________________________________________ Title: __________________________________
If the filer requests a copy of the Application for Withdrawal an additional exact copy of the filed document
along with a return-addressed envelope with adequate first-class postage must also be submitted.
Under GRAMA {63G-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes,
you may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity.
State of Utah
DEPARTMENT OF COMMERCE
Division of Corporations & Commercial Code
Application for Withdrawal
Entity Number: ________________
[ ] Profit Corporation
[ ] Non-Profit Corporation
This form cannot be hand written.
Authorized party must sign here after the form is printed
Mailing/Faxing Information:
www.corporations.utah.gov/contactus.html
www.corporations.utah.gov
