State of Missouri Corporations Division PO Box 778 / 600 W. Main St., Rm. 322 Jefferson City, MO 65102 John R. Ashcroft, Secretary of State 1. The Corporation's name is (Submit with filing fee of $10.00 and Certificate of Tax Clearance issued by the Missouri Department of Revenue) Application for Certificate of Withdrawal of a Foreign Nonprofit Corporation 2. The corporation is not transacting business in this state, and it surrenders its authority to transact business in the State of Missouri. 3. The corporation revokes the authority of its registered agent to accept service on its behalf and appoints the Missouri Secretary of State as its agent for service of process in any proceeding based on a cause of action arising during the time it was authorized to do business in the State of Missouri. 4. The mailing address to which the Secretary of State may mail a copy of any service of process is: Address and it is organized and existing under the laws of Missouri Charter #: 5. The corporation will notify the Secretary of State of any future changes of mailing address. City, State, Zip 6. The effective date of this document is the date it is filed by the Secretary of State of Missouri unless a future date is otherwise indicated: (Date may not be more than 90 days after the filing date in this Office) In Affirmation thereof, the facts stated above are true and correct: (The undersigned understands that false statements made in this filing are subject to the penalties provided under Section 575.040, RSMo) Authorized Signature of Officer or Chairman of the Board Printed Name Title Date Name and address to return filed document: Name: Address: City, State, and Zip Code: Corp. 49 (01/2017) American LegalNet, Inc. www.FormsWorkFlow.com Form 943 Missouri Tax I.D. Number Charter Number Missouri Department of Revenue Request for Tax Clearance Department Use Only (MM/DD/YY) Federal Employer I.D. Number 1. Does this business have Missouri employees for which they are required to withhold Missouri taxes? 2. Do you pay contributions to the Division of Employment Security? r Yes r No If yes, what is that account number? _______________________________ Business Ownership r Yes r No If there has been a change in the ownership of your business, you may need to contact Business Tax Registration at (573) 751-5860 to ensure your account is property registered. r Corporation r Partnership r Sole Proprietorship r Limited Liability Company Taxed as: r Corporation r Partnership Name Mailing Address City r Sole Owner State Zip Code Doing Business As Name (DBA) 1. I am completing the following transaction with the Missouri Secretary of State's Office. Reason(s) for Request r Reinstatement r Withdrawal or Termination r Merger -- Date of Merger ___ ___ / ___ ___ / ___ ___ ___ ___ r Selling Business Assets r Financial Closing r MBE or WBE All tax types and the account with the Division of Employment Security will be reviewed and must be filed and paid in full. 2. I am completing the following transaction: r Missouri Quality Jobs r Other ________________________________________________________________________________ All tax types and the account with the Division of Employment Security will be reviewed and must be filed and paid in full. 3. I require a sales or use tax Certificate of No Tax Due for the following: Select all that apply. r Business License r Liquor License r Other (if not listed) _____________________________________________________ 4. I require a sales or use tax Vendor No Tax Due to obtain or renew a contract with the state of Missouri. Contact person ______________________________________________ Phone Number ( ___ ___ ___ ) ___ ___ ___-___ ___ ___ ___ If there has been a name change for this corporation, please provide prior name. _____________________________________________________________ If individual income tax returns have been previously filed in another state, please provide a list of the states and years filed. Attach additional page(s) to this form if needed. Your Social Security Number | | | | | | | | Corporations Parent Corporation Information: Missouri Tax Identification Number | | | | | | | Federal Employer Identification Number | | | | | | | | Missouri corporation franchise tax returns cannot be filed consolidated and must be filed by each corporation. Sole Proprietorships r This corporation files consolidated corporation income tax returns in Missouri. Spouse's Social Security Number | | | | | | | | Authorization All correspondence will be released to the person authorized below. Release of this information to a third party (such as an accountant) at the request of the taxpayer does not give the third party authority to request further information from the Department. To obtain additional information or to represent the taxpayer before the Department, the taxpayer must execute a Power of Attorney designating the third party as its representative. Name of Person Authorized to Receive This Information Title Phone Number (___)___-____ Address E-mail Address of Authorized Person City State Zip Code Signature Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. Signature of Owner or Officer Title Phone Number (___)___-____ Printed Name of Owner or Officer Please fax the results to (___)___-____ Taxation Division P.O. Box 3666 Jefferson City, MO 65105-3666 Phone: (573) 751-9268 Fax: (573) 522-1265 E-mail: taxclearance@dor.mo.gov Form 943 (Revised 12-2014) Mail to: *14012010001* 14012010001 American LegalNet, Inc. www.FormsWorkFlow.com Frequently Asked Questions 1. What if I don't know my Missouri tax identification number? The Missouri tax identification number is assigned by the Missouri Department of Revenue at the time you register for the reporting of sales, use, withholding, corporation income, or corporation franchise tax. If you have not registered your business or need to check on the status of a registration, please contact Business Tax Registration at (573) 751-5860. 2. What is my federal employer identification number? The Internal Revenue Service issues your federal employer identification number when you register to file federal taxes. If you do not have this number, we will review the account based on the information provided. 3. What is my corporation charter number or certificate of authority number? Your corporate charter number is issued to a Missouri corporation, limited liability company o