NY C DEP AR TME NT OF FI NANC E 
 CO LLE CTI ON DI VIS IO N
            TM

Financ e                 RE QU ES T FOR                            CO NSEN T TO DISSOLUTION

Mai l to: NYC Department of Finance, Collection Division , Quality Management/Special              Project, 59 Maiden  Lan e, 28th Fl., New Yor k, NY 10038

In stru ction s:         Pl ease com ple te, sig n and date where                     indicate              d and mail to the addre            ss abov e.
Un der Sect io n 100 4 of the Busin             ess Corpo rat io n La w, As of Octo ber 1, 200 9, Tax Clear                                                    -
ance must       be obtained          from th e NYC       Depart men t of Fin ance (Fin ance)                                          when dissolvin           g
a corpor    ation.       The Dissolu ti on Conse         nt mus t be attac hed to the                                 Ce rt if ic at e of Di ss olut ion
of corpora  tio ns th at have         done bus iness in an d incu rre d ta x lia bil ity to the City                                               of New
Yor k. If yo u are filing            a Re que st for Disso luti on on behalf of a co rp oration,                                            you will need
to obt ain and su bm it a sig ned an d da ted Po we r of Atto rn ey with th is request.

Re qu est for Consent            of the Com missi oner             of Fina nce for the disso luti on of:

___ ___ ____________       ______    ___ __ ____ ______    ____ ___ ____              __ _____ ___ ____ ____ ____ ___________
                           Cor po ra tion Na me                                                             Ta xpayer Identi ficat ion Number

Add re ss:  ____ _________       ____ __ ___ ____ __ ____ ____ ____ ____ ____ ____ ___ ____ ____ ____ ___________
                                                         Nu mbe r an d Stre et

Ci ty: _________________             __ _______ ____ __ __         State: ___ ___                           Zip Code:  __ ____ ____ __________

Tel eph one                                                        Email
Numbe    r : (_ ____ __) ______      ___ ______ ___ __ ____ __     Addre              ss: ____ ____ ___ ____ ____ ____ ___________

Stat e an d Coun ty                                                Dat e of
of Inco rp oration:_______       ____ __ ___ ____ ____ ____Inco_                      rporation :_____ _____/                         ________/__ __________

Da te Busi ness                                                    Date               Bu siness
Beg an (i n NYC)____:      ___ ___/  ___ ____/___ ____ ___ ___End ed (i n NYC_____):                                  _____/          _____ _____/ __________

__ __ ___ ______________             __ __ __ ___ ____ __ ____ _   ____ _____                      ___ ____ ____ ____ ___ ____ __________
            Prin t or Type       Name of Si gn er                                                  Prin t or Type      Tit le of Sig ner

__ __ ___ ______________             __ __ __ ___ ____ __ ____ _          ________________________          /________________________ /________________________
                         Si gnat ure                                                                                  Dat e
                                                                                                                       Requ est for Disso lution - Re v. 01.07.2014