TR-193.1(12/16)

Office of Processing and Taxpayer Services
W A Harriman Campus, Albany NY 12227-0852

    Affidavit for Surrender of Authority for Foreign Corporations

Legal name of corporation:  
Employer identification number (EIN):  
I,                                               (print name), being duly sworn, hereby depose and say:

 1.  I am the                                                      (title, must be an officer or legal representative)
    of                                                             (legal name of corporation)

 2. The corporation requests to surrender its authority to do business in New York State as of           (today’s
    date, mm-dd-yy)

 3.  The corporation was not subject to tax under Article 9 or Article 9-A, and therefore did not file New York State 
    tax returns or reports for the following periods that began on or after January 1, 2015 (attach additional sheets if 
    necessary):
      Tax period beginning date (mm-dd-yy) Tax period ending date (mm-dd-yy)

4.  I acknowledge that surrendering this corporation’s authority does not end its obligation to pay taxes if it is subject to tax 
    or becomes subject to tax in New York State.

  5.  I acknowledge that this affidavit does not start the period of limitation within which franchise tax may be assessed.

6.  I acknowledge that this corporation must satisfy all open tax periods prior to consent being issued.

                                                                                                        (Certification on page 2)

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Page 2 of 2  TR-193.1 (12/16)

  7.  I certify that the foregoing statements are true and correct to the best of my knowledge and belief.

Signature

Notary acknowledgement
Sworn to before me this       day of   , 20 

                                      Notary stamp

Notary Public