New York State 
                                                                         Department of State 
                                                               DIVISION OF CORPORATIONS, 
                                                                         STATE RECORDS AND  
                                                               UNIFORM COMMERCIAL CODE 
                                                                         One Commerce Plaza 
                                                                         99 Washington Ave. 
                                                                         Albany, NY 12231-0001 
                                                                         https://dos.ny.gov                                         
DOCUMENT AND CERTIFICATE COVER SHEET 

Contact Information 
 
Name:   ______________________________________________________________________________ 
 
Mailing Address:_______________________________________________________________________ 
                   
              _____________________________________________________________________________ 
 
Email Address: ______________________________________________________________________ 
 
Phone Number:  ______________________________________________________________________ 
 
Request for Filing of Document 
 
Exact Name of Entity: __________________________________________________________ 
____________________________________________________________ 
 
Document Type:_______________________________________________________________  
                                   (i.e., Certificate of Incorporation, Articles of Organization, Certificate of Amendment, etc.): 
 
Request for Copies or Certificates of Status (Check the appropriate box) 
 
Exact Name of Entity: __________________________________________________________ 

□ Certified Copies of all Documents on File ($10 per document) 

□ Plain Copies of all Documents on File ($5 per document) 

□Certified Copy of _____________________________________________________ ($10 per document) 
                               (specify document) 

□ Plain Copy of ________________________________________________________ ($5 per document) 
                               (specify document) 

□ Certificate of Status - Long Form ($25 per document) 

□ Certificate of Status - Short Form ($25 per document)   
 
Method of Delivery of Filing Receipt or Other Document  

All documents will be returned to the email address listed above with the exception of certified and 
uncertified copies filed before July 1990. 

DOS-2183-f (04/22) 

                                                                                                  New York State 
                                                                                            Department of State 
                                                                                   DIVISION OF CORPORATIONS, 
                                                                                   STATE RECORDS AND  
                                                                                   UNIFORM COMMERCIAL CODE 
                                                                                             One Commerce Plaza 
                                                                                                  99 Washington Ave. 
                                                                                             Albany, NY 12231-0001 
                                                                                                  https://dos.ny.gov 
 
          CERTIFICATE OF SURRENDER OF AUTHORITY 

                           OF 
 
                          (Insert Name of Foreign Corporation) 
 
                          Under Section 1311 of the Not-for-Profit Corporation Law 
 
 FIRST    : The name of the corporation as it appears on the index of names in the Department of 

 State is: 

 The fictitious name the corporation has agreed to use in New York State, if applicable, is: 
 
 SECOND:                  The jurisdiction of incorporation is: 
 
 THIRD: The date the Application of Authority was filed with the Department of State is: 
 
 FOURTH: The corporation surrenders its authority to conduct activities in New York State. 
 
 FIFTH: The corporation revokes the authority of its registered agent, if any, previously designated. 
 
 SIXTH: The corporation consents that process against it in any action or special proceeding 
 based upon any liability or obligation incurred by it within this state before the filing of the 
 certificate of surrender of authority may be served on the Secretary of State after the filing thereof 
 
                           (continued) 

 DOS-1564-f  (Rev. 12/22)                                                                               Page 1 of 2 

in the manner set forth in paragraph (b) of Section 306 (Service of process). The post office 
address to which the Secretary of State shall mail a copy of any process against it served upon the 
Secretary of State by personal delivery is: 
 
                                                                                                                                                                                                         . 
The email address to which the Secretary of State shall email a notice of the fact that process 
against the corporation has been served electronically upon the Secretary of State is: 
 
                      . 
 
                X 
                               (Signature)                                                                                    (Name of Signer)                              
 
   (Title of Signer) 
 
CERTIFICATE OF SURRENDER OF AUTHORITY 
OF 
 
(Insert Name of Foreign Corporation) 
 
Under Section 1311 of the Not-for-Profit Corporation Law 
 
Filer’s Name    

Address    

City, State and Zip Code 

NOTES: 
1. The name of the corporation and the date the Application for Authority was filed must be exactly as they appear on the records 
of the Department of State. This information should be verified on the Department of State's website at https://dos.ny.gov/.  
2. This certificate must be signed by an officer, director or duly authorized person. 
3. Attach the consent of the New York State Tax Commission. To request consent, call the State Tax Commission at 
(518) 485-2639. 
4. The fee for filing this certificate is$30, made payable to the Department of State. 
 
For Office Use Only 

 DOS-1564-f  (Rev. 12/22) Page 2 of 2