D5 
                 Depa~ment of                                                                                                    Rev. 3/18 
Ohio I Taxation 
                 Tax Release Unit 
                 P.O. Box 182382 
                 Columbus, OH 43218-2382 

                                  Notification of Dissolution or Surrender 

 All corporations seeking a dissolution, surrender, consolidation, merger or conversion must submit this form to the Ohio 
 Department of Taxation at least 30 days prior to the date the corporation intends to file with the Ohio Secretary of State. 
 A Certificate of Tax Clearance will not be issued until all taxes/fees administered by the  ax T           ommissionerCare fi led and 
 paid. Review the notification of dissolution or surrender instructions before completing. 

 1.Name of corporation
                                                            (as recorded with the Ohio Secretary of State) 
   DBA (if applicable)
   Address
   FEIN                                                                        Ohio charter/entity no. 
   Date qualified in Ohio                    Incorporation date                            State of incorporation 
 2.Select corporation/entity type:

 DomesticD For-Profit              DDomestic Nonprofit    DLLC 

 ForeignD For-Profit               DForeign Nonprofit     DDomestic/Foreign Nonprofi t Agricultural Cooperative 
 3.Select dissolution/surrender method:  DCertificate of Tax Clearance         DAffidavit 
   (Domestic for-profit corporations must select Certificate of Tax Clearance) 

 4.Select reason for dissolution/surrender: D Consolidation                  D Conversion D Dissolution/Surrender
 MergerD Other   D 

 5.Date Ohio business activity ceased or will cease (mm/dd/yy):
   Ending date of last payroll subject to Ohio withholding (mm/dd/yy):
   Date corporation intends to dissolve its Ohio charter/license (mm/dd/yy):
 6.Type of business activity/product sold:                                                                 NAICS code: 
 7.Name, address, telephone and fax number of person to whom inquiries may be made. If this is a
   representative, please include a Declaration of Tax Representative (Ohio TBOR 1):

 8. Select each tax applicable to this corporation and provide information requested. See section 3 of the instructions for
   information on how to close certain accounts with the Ohio Department of Taxation:

                      Tax Type                                               Ohio Account No.              Date Final Return Filed 

 D Commercial activity tax 

   Consumer use tax/direct pay permit 
 D 
   Corporation franchise tax 
 D 
   Employer withholding tax
 D 
 Excise/energy taxes 
 D (motor fuel, alcohol, tobacco, public utility) 
   Financial institutions tax (also see #9 on page 2) 
 D 
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                                                                                                                      D5 
                                                                                                                      Rev. 4/17 

    Sales tax/sellers use tax 
D 
D   School district employer withholding tax 

D   Wireless 9-1-1- fee 

D   Other (list tax type) 
(Include an additional sheet if necessary) 
9. If you fi le the financial institution tax as part of a group, provide the name and FIT account number of the reporting member:

10.Name, address, FEIN and Ohio charter/license number of the entity (if any) that is continuing the business activities of
    the dissolving corporation:

11.List any matters pending with the Ohio Department of Taxation, such as petitions for reassessment, requests for refunds,
    etc. and list any appeals to the Board of Tax Appeals:

 12. Identify the person and mailing address where the Certificate of Tax Clearance should be sent (if different from response
    #7). If this is a representative, include an Ohio TBOR 1:

13.List each officer’s and director’s name, address and SSN (include additional list if necessary):

                  Name and Title                                  Home Address                                 SSN 

14. I declare and affirm, under penalties provided by law, that this application has been examined by me and the state-
    ments contained therein are true to the best of my information, knowledge and belief.      By my signature, as an officer of 
the corporation or as the person who will execute the dissolution/surrender, I (i) acknowledge that all of my tax accounts with 
the Ohio Department of Taxation will be closed as of the date provided in section 5 (the latter of last day of businessor last day 
of payroll); (ii) acknowledge that the dissolution/surrender does not relieve the corporation for payment of all taxes/fees 
administered by and required to be paid to the  ax Tommissioner;C and (iii) acknowledge, if the corporation is a domestic 
nonprofit corporation organized under Ohio Revised Code (R.C.) chapter 1702 or a domestic nonprofit agricultural cooperative 
organized under R.C. chapter 1729, the applicability of R.C. sections 1702.55 and 1729.25, respectively.

    Name                                                          Signature 

 Title                                                            Date 
    Send or e-mail the completed and signed form to:                                For overnight delivery ONLY: 
    Ohio Department of Taxation                                                     Ohio Department of Taxation 
    Tax Release Unit                                                                Tax Release Unit 
    P.O. Box 182382                                                                 4485 Northland Ridge Blvd. 
    Columbus, OH 43218-2382                                                         Columbus, OH 43229 

    E-mail: dissolution@tax.state.oh.us      Fax number: 1-206-984-0378             Telephone inquiries: 1-855-995-4422  

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