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 1310 of the Business 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 business 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 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 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: 

                                                                                                                         . 
                    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 changed to 
                    read as follows: 

                                                                                                                         . 
 
 DOS-1563-f (Rev. 12/22)                                                                                          Page 1 of 2 

       X 
                           (Signature)                                                (Name of Signer) 

                                                                                        (Title of Signer) 

                        CERTIFICATE OF SURRENDER OF AUTHORITY 
                                             OF 

                                             (Insert Name of Foreign Corporation) 

                                   Under Section 1310 of the Business Corporation Law 

Filer’s Name and Mailing Address: 

         Name: 

         Company, if Applicable: 

         Mailing 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 NYS Department of
Taxation and Finance at (518) 485-2639.
4. The fee for filing this certificate is $60, made payable to the Department of State.
5. You are not required to use this form. You may draft your own form or use forms available at legal stationery
stores. The Department of State recommends that legal documents be prepared under the guidance of an attorney.

For Office Use Only 

DOS-1563-f (Rev. 12/22)                                                                                           Page 2 of 2