FLORIDA DEPARTMENT OF STATE  
                                DIVISION OF CORPORATIONS 
 
Attached is a form to withdraw the authority of a foreign corporation that is transacting business or conducting 
affairs in Florida.  The requirements are as follows: 
 
  Pursuant to section 607.1520 or 617.1520, Florida Statutes, the attached application should be 
   completed in its entirety. 
 
  The fees are as follows: 
 
   Filing Fee -                                          $ 35.00  
    
        Certified Copy (optional) -                      $ 8.75  
   
   Certificate of Status (additional) (optional) -       $ 8.75 
 
  Checks should be made payable to the Florida Department of State. 
 
  Please complete the attached cover letter and return it with the withdrawal application and fee. 
 
   Mailing Address:                                     Street Address: 
   Amendment Section                                    Amendment Section 
   Division of Corporations                             Division of Corporations 
   P.O. Box 6327                                        The Centre of Tallahassee 
   Tallahassee, FL 32314                                2415 N. Monroe Street, Suite 810 
                                                        Tallahassee, FL 32303 
 
For further information, you may call (850) 245-6050. 
 
CR2E023 (4/13) 
 

                                       COVER LETTER 
                                                     
TO:   Amendment Section 
      Division of Corporations 
 
SUBJECT:  ___________________________________________________________________ 
                                       (Name of Corporation) 
 
DOCUMENT NUMBER:                                                                                                
 
The enclosed withdrawal application and fee are submitted for filing. 
 
Please return all correspondence concerning this matter to the following: 
 
                                        (Name of Person) 
                                                     
                                        (Firm/Company) 
                                                     
                                              (Address) 
                                                     
                                        (City/State and Zip code) 
                                                     
For further information concerning this matter, please call: 
 
_______________________________________ at (_________)__________________________________ 
             (Name of Person)                      (Area Code & Daytime Telephone Number) 
 
Enclosed is a check for the amount: 
 
☐ $35 Filing Fee  ☐ $43.75 Filing Fee &    ☐ $43.75 Filing Fee &                          ☐ $52.50 Filing Fee, 
                   Certificate of Status      Certified Copy                 Certificate of Status & Certified  
                                                                           (Additional copy is          Copy (Additional copy is enclosed) 
                                                                            Enclosed) 
 
      Mailing Address:                       Street Address: 
      Amendment Section                      Amendment Section 
      Division of Corporations               Division of Corporations 
      P.O. Box 6327                          The Centre of Tallahassee 
      Tallahassee, FL 32314                  2415 N. Monroe Street, Suite 810 
                                             Tallahassee, FL 32303 
                                        

 APPLICATION BY FOREIGN CORPORATION FOR WITHDRAWAL OF 
 AUTHORITY TO TRANSACT BUSINESS OR CONDUCT AFFAIRS IN FLORIDA 
                                                                    
                                (Name of Corporation) 
                                                                    
         (Document Number of Corporation (if known)                                 
                                                                    
    (Incorporated Under Laws of and date authorized to transact business/conduct its affairs) 
 
This corporation is no longer transacting business or conducting affairs within the State of Florida and hereby 
voluntarily surrenders its authority to transact business or conduct affairs in Florida. 
 
This corporation revokes the authority of its registered agent in Florida to accept service on its behalf and 
appoints the Department of State as its agent for service of process based on a cause of action arising during the 
time it was authorized to transact business or conduct affairs in Florida. 
 
The following is a current mailing address for the corporation: 
 
                                                           (Mailing Address) 
                                                                    
                                                           (City/ State /Zip) 
                                                                    
The corporation agrees to notify the Department of State in the future of any change in its mailing address. 
 
 (Signature of a director, president or other officer - if in the hands of a             (Date) 
   receiver or other court appointed fiduciary, by that fiduciary) 
 
               (Typed or printed name of person signing)                                  (Title of person signing) 
                                                                    
                               FILING FEE $35