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Michigan Department of Treasury 501 Rev. 09-12 Reset Form Tax Clearance Request for Corporation Dissolution or Withdrawal Issued under authority of Public Act 228 of 1975 as amended. NOTICE TO CORPORATIONS A tax clearance certificate must be obtained within 60 days of dissolution or withdrawal of a corporation from the State of Michigan. A certificate will not be issued until all returns are filed and all liabilities are paid. For additional information see Tax Clearance Information Form 515. This form must be completed in its entirety. Federal Employer Identification Number FEIN Corporate Identification CID Number Corporation Name list any corporate name change below Street Address City Date Business Actually Discontinued in Michigan mm/dd/yyyy Ending Date of Last Payroll Subject to Michigan Withholding mm/dd/yyyy Date Incorporated mm/dd/yyyy Date Foreign Corporation Authorized to Transact Business in Michigan mm/dd/yyyy Type of Action Requested of the Department of Licensing and Regulatory Affairs Dissolution State ZIP Code Effective Date mm/dd/yyyy Withdrawal From the State of Michigan How does your corporation file the Michigan Annual Report Profit Non-Profit Is corporation undergoing 12-month liquidation Yes If yes date liquidation will be complete mm/dd/yyyy No Name Changes and Dates If this corporation had no tax liability or was not required to register with the Michigan Department of Treasury provide a detailed explanation* Substantiate with attachments. Is there a corporation assuming assets or continuing activity of this corporation If yes enter Name Enter FEIN Certification I declare under penalty of perjury that I am the owner officer or member of the business on which tax clearance is requested and that the information entered is true. Submit a Limited Power of Attorney Form 3840 if not the owner officer or member Print Name Title Telephone Number Signature Contact Address Date Attach a copy of your final tax returns with proof of payment if any and mail to PO Box 30168 Lansing MI 48909. This form must be completed in its entirety. Federal Employer Identification Number FEIN Corporate Identification CID Number Corporation Name list any corporate name change below Street Address City Date Business Actually Discontinued in Michigan mm/dd/yyyy Ending Date of Last Payroll Subject to Michigan Withholding mm/dd/yyyy Date Incorporated mm/dd/yyyy Date Foreign Corporation Authorized to Transact Business in Michigan mm/dd/yyyy Type of Action Requested of the Department of Licensing and Regulatory Affairs Dissolution State ZIP Code Effective Date mm/dd/yyyy Withdrawal From the State of Michigan How does your corporation file the Michigan Annual Report Profit Non-Profit Is corporation undergoing 12-month liquidation Yes If yes date liquidation will be complete mm/dd/yyyy No Name Changes and Dates If this corporation had no tax liability or was not required to register with the Michigan Department of Treasury provide a detailed explanation* Substantiate with attachments. Is there a corporation assuming assets or continuing activity of this corporation If yes enter Name Enter FEIN Certification I declare under penalty of perjury that I am the owner officer or member of the business on which tax clearance is requested and that the information entered is true.

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