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. 02/16)                                                                               Page 1 of 2 

in the manner set forth in paragraph (b) of Section 306 (Service of process). The address to which 
the Secretary of State shall mail a copy of any process against it served upon him or her 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 www.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. 02/16) Page 2 of 2