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Affidavit For Reinstatement Of Domestic Corporation Form. This is a Indiana form and can be use in Department Of Revenue Statewide.
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Tags: Affidavit For Reinstatement Of Domestic Corporation, AD-19, Indiana Statewide, Department Of Revenue
AD-19
Indiana Department of Revenue
SF 49514
Affidavit for Reinstatement of Domestic Corporation
(R2/ 10-07)
State of Indiana
County of _____________
)
) SS
)
_________________________________________________ being duly sworn according to law, affirms that he/she is the
(name)
___________________________________________ of _______________________________ a corporation organized
(official capacity)
(corporation name)
under the laws of the State of Indiana, _____________________________ , with its principal office located at address
(incorporation date)
____________________________________________________ , city _________________________ , state _________ ,
zip __________________ , and identified by Federal ID #_________________________________ , and Indiana sales and/or
withholding tax TID # _____________________________________ and that he/she makes this affidavit for and on behalf of this
corporation. He/She states that the books and records of this corporation are kept at _______________________________________ ,
(address)
in care of ________________________________________________ , and that this corporation is engaged in the business of
(name)
__________________________________________________________ . To the best of my belief and knowledge, all of
(primary purpose)
the said corporation’s Indiana taxable income received on and after May 1, 1933, has been included in Indiana income tax
returns filed with the Indiana Department of Revenue and that all tax has been paid. The latest Indiana sales and/or withholding tax
return were filed for the month/year ________/_________ , under the name of ___________________________________________ .
(name)
That this affidavit 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 effect 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.
_______________________________________
Signature
_______________________________________
Title
State of Indiana
County of _______________
)
) SS
)
Subscribed before me, a Notary Public in and for said county and state, this ____________ day of __________________ , _______ .
__________________________________________________ _________________________________________________
Commission Expiration Date
Signature
__________________________________________________ _________________________________________________
County of Residence
Printed Name
Mail to: Indiana Department of Revenue, Tax Administration, Room N203, 100 N. Senate Avenue, Indianapolis, IN 46204.
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