Affidavit For Reinstatement Of Domestic Corporation {49514}

AD-19 State Form 49514 (R3/ 10-10) Indiana Department of Revenue Affidavit for Reinstatement of Domestic Corporation ) ) SS County of _______________ ) _________________________________________________ being duly sworn according to law, affirms that he/she is the (name) State of Indiana ___________________________________________ of _______________________________ a corporation organized (official capacity) (corporation name) under the laws of the State of Indiana, _____________________________ , with its principal office located at address (incorporation date) ____________________________________________________ , city ________________________ , state _________ , zip _______________ , and identified by Federal ID #______________________________ , and Indiana sales and/or withholding tax TID # _______________________________ and that he/she makes this affidavit for and on behalf of this corporation. He/She states that the books and records of this corporation are kept at ____________________________ , (address) in care of ___________________________________________ , and that this corporation is engaged in the business of (name) __________________________________________________________ . To the best of my belief and knowledge, all of (primary purpose) the said corporation's Indiana taxable income received on and after May 1, 1933, has been included in Indiana income tax returns filed with the Indiana Department of Revenue and that all tax has been paid. The latest Indiana sales and/or withholding tax return were filed for the month/year _____/_____ , under the name of ___________________________ . (name) That this affidavit is made for the sole purpose of inducing the Indiana Department of Revenue, to issue a notice as provided by the applicable taxing acts to the effect that such corporation has paid all taxes due from it under the taxing acts which will permit the Indiana Secretary of State to reinstate the corporation to active status. ______________________________________ Signature ______________________________________ Title State of Indiana ) ) SS County of _________________ ) Subscribed before me, a Notary Public in and for said county and state, this ______ day of _______________ , _______ . _____________________________________________ Commission Expiration Date _____________________________________________ Signature _____________________________________________ County of Residence _____________________________________________ Printed Name Mail to: Indiana Department of Revenue, Tax Administration, P.O. Box 6197, Indianapolis, IN 46206. American LegalNet, Inc. www.FormsWorkFlow.com