Authorization to Dissolve an Entity

Authorization to Dissolve an Entity

Corporation Information

Corporation Name

FEIN

Address

City

State

Zip Code

Contact Information

First Name

Last Name

Address

City, State, Zip

Phone

Fax

Email

Authorization

Corporate Officer Name

Title

Dissolution Fee

Corporate Officer Signature

Date

Credit Card Authorization

Card Type

Name on the Credit Card

Credit Card Number

Expiration Date

Security (CSV) Code

Billing Address

City, State, Zip

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