325 Don Gaspar, Suite 300 Santa Fe, NM 87501 (800) 477-3632 www.sos.state.nm.us SECRETARY OF STATE DISSOLUTION/WITHDRAWAL APPLICATION FOR TAX CLEARANCE FOR ***INFORMATION MUST BE LEGIBLE*** DATE: __________________ RE: ______________________________________________________________________________ (PRINT EXACT CORPORATE NAME AS REGISTERED WITH OUR OFFICE) NM CORP # ____________________ TAXATION & REVENUE ID # _____________________ SUBJECT: TAX CLEARANCE REQUEST FOR DISSOLUTION/WITHDRAWAL THIS CORPORATION IS IN THE PROCESS OF DISSOLVING/WITHDRAWING FROM THE STATE OF NEW MEXICO AND IS REQUESTING TAX CLEARANCE. FINAL DAY OF BUSINESS: Month __________ Day __________ Year __________. NOTE: THE CORPORATION CANNOT BE ISSUED A TAX CLEARANCE FOR A FUTURE DATE OR IF IT IS DELINQUENT IN FILING REPORTS AND/OR PAYING FEES DUE. ALSO, A FINAL REPORT MAY BE REQUIRED THROUGH THE FINAL DAY OF BUSINESS. YOU WILL BE ADVISED ACCORDINGLY. _______________________________________________ SIGNATURE OF OFFICER OR AUTHORIZED AGENT NAME: ___________________________________________________ ADDRESS: ________________________________________________ CITY: ________________STATE: _______ZIP CODE: ____________ TELEPHONE: (_____)_______________________________________ MAIL TO: SECRETARY OF STATE TAX COMPLIANCE DIVISION 325 DON GASPAR, SUITE 300 SANTA FE, NM 87501 PHONE: (800) 477-3632 American LegalNet, Inc. www.FormsWorkFlow.com DOCUMENTS MUST BE TYPED OR PRINTED LEGIBLY Instructions For Completing Form FNP-WD (Application for Certificate of Withdrawal) Item 1 (QWHU WKH FRPSOHWH QDPH RI WKH FRUSRUDWLRQ DV LW FXUUHQWO\ DSSHDUV RQ WKH UHFRUGV RI WKH Secretary of State DQG WKH 10 &253 FKDUWHU ,' QXPEHU IRXQG RQ WKH &HUWLILFDWH RI $XWKRULW\ ,WHP Enter the state or country where the corporation originally filed to become incorporated. Item 2: Item 3: These statements are required to be set forth in the application for Certificate of Withdrawal. By signing this application, the corporation is affirming these statements. Item 4: Enter the mailing address to which a copy of any process against the corporation could be mailed by the New Mexico Secretary of State. Date and Execution: Enter the date the application was executed (signed). Enter the name of the applying corporation on the line provided. The application must be signed by two authorized officers of the corporation. NOTE: Attach the Secretary of State clearance for withdrawal to the application. American LegalNet, Inc. www.FormsWorkFlow.com SUBMIT ORIGINAL AND A COPY TYPE OR PRINT LEGIBLY Foreign Nonprofit Corporation APPLICATION FOR CERTIFICATE OF WITHDRAWAL The undersigned corporation, in order to apply for a Certificate of Withdrawal under the New Mexico Nonprofit Corporation Act, submits the following statement to the Secretary of State: 1. The name of the corporation is (include NM CORP #): _________________________________ ______________________________________________________________________________ 2. It is incorporated under the laws of: _______________________________________________ 3. It is not conducting affairs in New Mexico. It surrenders its authority to conduct affairs in New Mexico. It revokes the authority of its registered agent in New Mexico to accept service of process, and consents that service of process in any action, suit or proceeding based upon any cause of action arising in New Mexico during the time the corporation was authorized to conduct affairs in this state may thereafter be made on the corporation by service thereof on the Secretary of State of New Mexico. 4. The mailing address to which the Secretary of State of New Mexico may mail a copy of any process against the corporation that may be served on it is: ______________________________ ______________________________________________________________________________ Dated: ________________________ ____________________________________ Name of Corporation By_________________________________ Signature of Authorized Officer By_________________________________ Signature of Authorized Officer NOTE: ATTACH THE CLEARANCE FOR WITHDRAWAL TO THIS APPLICATION. Form FNP-WD (revised 06/13) Two officers must sign: American LegalNet, Inc. www.FormsWorkFlow.com