23800011016 REV-238 CM (12-04) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF COMPLIANCE OUT OF EXISTENCE/MERGER SECTION PO BOX 280947 HARRISBURG, PA 17128-0947 TELEPHONE NUMBER (717) 783-6052 TT# (800) 447-3020 (Services for Taxpayers with Special Hearing and/or Speaking Needs Only) DEPARTMENT USE ONLY OUT OF EXISTENCE/WITHDRAWAL AFFIDAVIT PLEASE PRINT OR TYPE INFORMATION BOX NUMBER TAX TYPE K- THIS FORM WILL NOT BE PROCESSED IF NOT PROPERLY SIGNED AND NOTARIZED NOTE: If filing a final RCT-101 corporate report for the year 2002 and forward, complete the “corporate status change” section in the RCT-101 in lieu of filing this form. NOTE: The reverse side of this form must be completed. Section A pertains to a PA corporation or a foreign corporation that operated wholly within Pennsylvania. Section B pertains to all other foreign corporations. Date of Incorporation or Certificate of Authority Account ID/Corp. Box # State of Incorporation Entity ID (EIN) Name of Corporation/Taxpayer I, the “Affiant,”was connected with the above corporation and have knowledge of its affairs. Said corporation ceased to transact business in Pennsylvania on or about * , Month Day and all assets were sold, assigned or distributed on Year ,and since that time, Month Day Year the corporation has not owned any property located in Pennsylvania, nor maintained an office therein, nor has performed any sales activity, and does not intend to transact further business in the Commonwealth. * If corporation never transacted business or held assets in Pennsylvania, please use the words N E V E R T R A NSA C TED B US I NESS in place of a cessation date. The filing of this Affidavit does not affect the status of the Certificate of Incorporation/Authority of this corporation but does permit the Department of State to relinquish the use of the present name of the corporation to another corporation. T h i s a f f i d a v i t i s n o t t o b e f i l e d b y a PA c o r p o r a t i o n u t i l i z i n g i t s PA c h a r t e r t o c o n d u c t b u s i n e s s i n a n o t h e r s t a t e . Out of state corporations soliciting business in Pennsylvania are subject to tax and should file this document only upon ceasing activity in Pennsylvania. Sworn to and subscribed before me this day of , year (Notary Public, District Justice, or Authorized Agent, Department of Revenue) My commission expires (Signature of Affiant) TITLE: , year (Present address of Affiant) (Notary Signature and Seal) Telephone Number ( ) PLEASE P R I N T O R T Y P E I N F O R M AT I O N NO FILING FEE 23800011016 American LegalNet, Inc. www.FormsWorkflow.com 2 3 8 0 0 0 1 2 0 1 7 DISTRIBUTION OF ASSETS THIS SCHEDULE MUST BE COMPLETED. ENTER “NONE” ONLY IF THE CORPORATION HAS NO ASSETS AND/OR LIABILITIES. Please Print or Type Name of Corporation Account ID/ Corp. Box # Business Address Date of Final Distribution City State Zip Code A. CORPORATION OPERATING 100% WITHIN PA MUST COMPLETE THIS SECTION (Provide copies of Federal Form 1099-DIV) SHARES OF STOCK OF EACH STOCKHOLDER NUMBER Stockholder Name Street Address City City City DESCRIPTION AMOUNT State Zip Code State Zip Code State Zip Code Social Security No. City Stockholder Name Street Address DATE Social Security No. Stockholder Name Street Address AMOUNT Social Security No. Stockholder Name Street Address DATE AMOUNT AND NATURE OF OTHER ASSETS RECEIVED BY EACH STOCKHOLDER Social Security No. Stockholder Name Street Address PAR VALUE MONEY RECEIVED BY EACH STOCKHOLDER State Zip Code Social Security No. City State Zip Code B. CORPORATIONS WITHDRAWING FROM PA BUT CONTINUING OPERATIONS OUTSIDE OF PA MUST PROVIDE THE FOLLOWING INFORMATION AND/OR DOCUMENT(S). 1. FULL DETAILS OF DISPOSITION OF PA PROPERTY. ATTACH COPIES OF FEDERAL SCHEDULE D AND/OR FEDERAL FORM 4797, IF APPLICABLE. 2. PLEASE INDICATE IF SALES IN PA WILL CONTINUE AFTER DATE OF CESSATION. IF SO, HOW WILL THEY BE NEGOTIATED AND BY WHOM? ATTACH STATEMENT CONTAINING THE REQUIRED INFORMATION IF ADDITIONAL SPACE IS NEEDED. IF ANY INDIVIDUAL OR CORPORATION OTHER THAN STOCKHOLDERS AND CREDITORS RECEIVED ASSETS, LIST NAMES AND ADDRESSES OF EACH, AND AMOUNT OR VALUE RECEIVED BY EACH. ● ● ● IF ANY CONSIDERATION WAS PAID FOR ANY OF THE ASSETS, STATE NAME AND ADDRESS OF INDIVIDUAL OR CORPORATION MAKING SUCH PAYMENT AND EXACT AMOUNT PAID BY EACH. (ATTACH A SEPARATE SHEET TO THIS FORM.) IF ANY MONEY OR PROPERTY REMAINS UNDISTRIBUTED, STATE AMOUNT, NATURE AND VALUE OF SAME, AND STATE WHY IT HAS NOT BEEN DISTRIBUTED. (ATTACH A SEPARATE SHEET TO THIS FORM.) IF ANY REAL ESTATE HAS BEEN DISTRIBUTED OR SOLD WITHIN THE FINAL TAX PERIOD, GIVE THE DATE OF RECORDING TITLE TRANSFER WITH LOCAL RECORDER OF DEEDS. DATE : Name of Person Making this Report Present Street Address Signature Title City Date State Zip Code 2 3 8 0 0 0 1 2 0 1 7 American LegalNet, Inc. www.FormsWorkflow.com