PDF document

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!
State of Rhode Island This legal document
Department of State - Business Services Division should be typed.
All illegible
documents
Instructions for Filing will be REJECTED.
Application for Certificate of Withdrawl for a Foreign Business Corporation
Section 7-1.2-1412 and 7-1.2-1413 of the General Laws of Rhode Island, 1956, as amended
The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant statutory provision.
This form and the information provided are not substitutes for the advice and services of an attorney and/or tax specialist.

All filings are public records under RIGL 38-2-1, et seq. This means all information is available to the public by a variety
of methods including, without limitations, inspections at our office, telephone inquiries and electronically through our online
database.

How to complete the form: How to pay the filing fee:
Before submitting this form, ensure your entity has The filing fee is payable either by mail via check made
filed its final tax return and is in good standing with payable to RI Department of State or in person via cash,
the Division of Taxation. You can confirm your tax credit card, or check at the Business Services Division, 148
status by contacting the Division of Taxation at W. River Street, Ste. 1, Providence, RI 02904. Contact our
tax.collections@tax.ri.gov or (401) 574-8941. office at (401) 222-3040 for further information.

1. List the entity’s ID number. The ID number can be found
How to confirm your filing:
by looking up your entity in the Corporate Database.
2. List the name of the corporation. The entity name can be Entity records are retrievable and viewable through our
verified through our Corporate Database. website. Successful filings will NOT result in a mailed
confirmation. Filings that cannot be processed will be posted
3. List the state of formation under whose laws the online and then returned. To confirm your submission and
company is incorporated. obtain evidence of your filing:
4. This section acknowledges that the entity is not • Go to our Corporate Database.
transacting business in this state and surrenders its
• Enter the name or ID number of your entity and click
authority to transact business in this state.
“Search.”
5. This section acknowledges that the Department of • Click on the link to your entity record, scroll down,
State will receive future service of process for the entity select “All Filings” and then “View Filing.”
regarding the transaction of business in Rhode Island. • Identify the desired type of filing and click on “PDF”
6. List the address where the RI Department of State may under “View PDF” to view and print the record.
mail a copy of service of process against the entity
received by the Department of State.
7. As required by RIGL 7-1.2-1413, the entity must certify
that it has paid all fees and taxes. Confirm with the RI
Division of Taxation that all tax obligations have been
satisfied. You can verify your tax status by emailing tax.
collections@tax.ri.gov.
8. If a receiver or trustee is responsible for the entity, that
receiver or trustee must execute this Application on
behalf of the entity.
9. Check “Date received” unless you prefer that the
Certificate of Withdrawl go into effect at a later date than
when the form is received in this office. Any later date
must be within 90 days of filing.
10. An Authorized Officer of the entity MUST sign and date
the form.

FORM 154 - Revised: 12/2023

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State of Rhode Island
Department of State - Business Services Division

Application for Certificate of Withdrawal STAMP
FOREIGN Business Corporation FOR
SECRETARY OF STATE
Filing Fee: $50.00 USE ONLY

Pursuant to the provisions of RIGL 7-1.2-1412 and 7-1.2-1413, the undersigned corporation hereby
applies for a Certificate of Withdrawal from the State of Rhode Island, and for that purpose submits
the following statement:
1. Entity ID Number: 2. The name of the corporation is:

3. It is incorporated under the laws of:

4. The corporation is not trasacting business in this state and surrenders its authority to transact business in this state.
5. It revokes the authority of its registered agent in this state 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 this state during the time the
corporation was authorized to transact business in this state may subsequently be made on the corporation by service
thereof on the Department of State of the State of Rhode Island.
6. The post office address to which the Department of State may mail a copy of any service of process against the
corporation that is served on the Department of State:

7.The corporation certifies that it has no outstanding tax obligations. As required by RIGL § 7-1.2-1413, the corporation has
paid all fees and taxes. [Note: Tax status can be verified by emailing tax.collections@tax.ri.gov.]
8. If the corporation is in the hands of a receiver or trustee, this Application for Certificate of Withdrawal must be executed
on behalf of the corporation by the receiver or trustee.
9. Date when this certificate of withdrawal will be effective: CHECK ONE BOX ONLY
Date received (Upon filing)
Later effective date (Date must be no more than 90 days from the date of filing) ___________________________

10. Under penalty of perjury, I declare and affirm that I have examined this Application for Certificate of Withdrawal,
including any accompanying attachments, and that all statements contained herein are true and correct.
Type or Print Name of Authorized Officer Date

Signature of Authorized Officer of the Corporation

MAIL TO:
Division of Business Services
148 W. River Street, Providence, Rhode Island 02904-2615 STAMP
Phone: (401) 222-3040 FOR
Website: www.sos.ri.gov SECRETARY OF STATE
USE ONLY

If you have any questions, please call us at (401) 222-3040, Monday through Friday,
between 8:30 a.m. and 4:30 p.m., or email corporations@sos.ri.gov.
FORM 154 - Revised: 12/2023

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        State of Rhode Island
        Department of State - Business Services Division

Filer Contact Information
        
In the event our office needs more information in order to complete the filing of this          document, we 
ask for the filer’s contact information. All fields are REQUIRED.

Name:                                                                               Date:

Entity Name:

Street Address:

City:                                    State:                                     Zip Code:

Email Address:                                                                      Phone Number:

If you have any questions, please call us at (401) 222-3040, Monday through Friday, 
between 8:30 a.m. and 4:30 p.m., or email corporations@sos.ri.gov.
                                                                                         FORM 154 - Revised:  12/2023

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