Page 1 of 6Form 564Last Revised: 06/2019 Toll Free: 877.767.3453 | Central Ohio: 614.466.3910 OhioSoS.gov | business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Filing Form Cover LetterPlease return the approval certificate to: Address: City: ZIP Code: Phone Number: E-mail Address: Check here if you would like to receive important notices via e-mail from the Ohio Secretary of State's office regarding Business Services. Check here if you would like to be signed up for our Filing Notification System for the business entity being created or updated by filing this form. This is a free service provided to notify you via e-mail when any document is filed on your business record. Please make checks or money orders payable to: "Ohio Secretary of State" Type of Service Being Requested: (PLEASE CHECK ONE BOX BELOW) Regular Service: Only the filing fee listed on page one of the form is required and the filing will be processed in approximately 3-7 business days. The processing time may vary based on the volume of filings received by our office. Expedite Service 1: By including an Expedite fee of $100.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 2 business days after it is received by our office. Expedite Service 2: By including an Expedite fee of $200.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 1 business day after it is received by our office. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Expedite Service 3: By including an Expedite fee of $300.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 4 hours after it is received by our office, if received by 1:00 p.m. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Preclearance Filing: A filing form, to be submitted at a later date for processing, may be submitted to be examined for the purpose of advising as to the acceptability of the proposed filing for a fee of $50.00. The Preclearance will be complete within 1-2 business days. Name (Individual or Business Name): To the Attention of (if necessary): State American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 6Form 564Last Revised: 06/2019Toll Free: 877.767.3453 Central Ohio: 614.466.3910 OhioSoS.gov business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Mail this form to one of the following: Regular Filing (non expedite) P.O. Box 1329 Columbus, OH 43216 Expedite Filing (Two business day processing time. Requires an additional $100.00) P.O. Box 1390 Columbus, OH 43216 Certificate of Surrender Foreign Licensed Corporation (For-Profit or Nonprofit Foreign Corporation) Filing Fee: $50 (143-SUR) Form Must Be Typed The foreign corporation, listed below, surrenders its license to transact business in Ohio. The address to which the secretary of state may mail any process against such corporation that may be served upon the secretary of state, and may mail any other notices, certificates, or statements: Name of Corporation Jurisdiction of Formation Ohio License Number Mailing Address City State ZIP Code Complete the following information.Form 564 Prescribed by: For screen readers, follow instructions located at this path. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 6Form 564Last Revised: 06/2019 Print Name By (if applicable) Signature Print Name By (if applicable) Signature Print Name By (if applicable) SignatureBy signing and submitting this form to the Ohio Secretary of State, the undersigned hereby certifies that he or she has the requisite authority to execute this document.Required Must be signed by an authorized officer, or by the receiver, trustee in bankruptcy, or other liquidator of such corporation. If authorized representative is an individual, then they must sign in the "signature" box and print their name in the "Print Name" box. If authorized representative is a business entity, not an individual, then please print the business name in the "signature" box, an authorized representative of the business entity must sign in the "By" box and print their name in the "Print Name" box. American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 6Form 564Last Revised: 06/2019 Name of Corporation Signature Title Name Mailing Address City State ZIP Code Notary Public Date Notified (MM/DD/YYYY) Acknowledged before me and subscribed in my presence on this date (MM/DD/YYYY)AFFIDAVIT BY A FOREIGN CORPORATIONComplete the information in this section.In lieu of dissolution releases from various governmental authorities (ORC section 1703.17(D)).The undersigned, being first duly sworn, declares that on the dates indicated below, each of the named state governmental agencies was advised IN WRITING of the scheduled date of filing of the Certificate of Surrender and was advised IN WRITING of the acknowledgement by the corporation that the surrender of its license does not release it of liability, if any, for payment of taxes and contributions due.AgencyOhio Department of Taxation Dissolution Section 4485 Northland Ridge Blvd. Columbus, Ohio 43229AgencyOhio Job & Family Services Status and Liability Section Data Correspondence Control Fax: 614-752-4811 Phone: 614-466-2319TreasurerNote: This affidavit must be signed by a person executing the certificate of surrender or by an officer of the corporation.SealOvernight Address: P.O. Box 182413 Columbus, OH 43218-2413Regular Address: P.O. Box 182413 Columbus, OH 43218-2413The treasurer of any county named below: Date Commission Expires (MM/DD/YYYY) Date Notified (MM/DD/YYYY) Date Notified (MM/DD/YYYY) American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 6Form 564Last Revised: 06/2019 State of County of Name of Officer Title of Officer Name of Corporation A. Has no personal property in any county in the state of Ohio B. Has personal property in the following county(ies) County County County Date Commission Expires (MM/DD/YYYY) Notary Public Acknowledged before me and subscribed in my presence on this date (MM/DD/YYYY)Seal Title Signature AFFIDAVIT OF PERSONAL PROPERTYofThat said corporation has: (Check one (1) of the following)Complete the information in this section.SS:, being first duly sworn, deposes and says that she/he isand this affidavit is made in compliance with section 1703.17 of the Ohio Revised Code.and that the net assets of said corporation are sufficient to pay all personal property taxes accrued to date. American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 6Form 564Last Revised: 06/2019Instructions for Certificate of SurrenderThis form should be used for a for-profit or nonprofit foreign corporation to file a certificate of surrender pursuant to Ohio Revised Code section 1703.17. Corporation Information Please provide the name of the corporation, the jurisdiction of formation and the Ohio license number assigned by our office. Mailing Address Please provide the address to which the secretary of state may mail any process against such corporation that may be served upon our office, and any other notices, certificates or statements. Additional Provisions If the information you wish to provide for the record does not fit on the form, please submit additional provisions on a single-sided, 8 275 x 11 sheet(s) of paper. Signature(s) After completing all information on the filing form, please make sure that page 2 is signed by an authorized officer of the corporation, or by the receiver, trustee in bankruptcy or other liquidator of such corporation. **Note: Our office cannot file or record a document which contains a social security number or tax identification number. Please do not enter a social security number or tax identification number, in any format, on this form. American LegalNet, Inc. www.FormsWorkFlow.com