Affidavit for Reinstatement of Domestic Corporation: Indiana Department of Revenue

Reinstating a dissolved domestic corporation that has been previously registered in the State of Indiana requires the execution of the following affidavit.

Extracted Text for Proper Search

SP 353 (5) 	
REINSTATEMENT DIRECTIONS DOMESTIC CORPORATIONS 
NONPROFIT CORPORATIONS 
LIMITED LIABILITY COMPANIES 
The following steps must be taken to reinstate your corporation or limited liability company when it has been 
administratively dissolved. Please direct any questions to our informat ion line at (317) 232-6576 or  
visit our website at www.IN.gov/sos	
. 
STEP 1  Obtain a Certificate of Clearance from the Indiana Department of Revenue by completing the 
 (AD19) Reinstatement Affidavit and (ROC-1) Responsible Officer Information forms.  	
This must be completed before anything may be  submitted to the Secretary of State’s office. 
You may either MAIL or DROP OFF the Reinstatemen t Affidavit and Responsible Officer forms to the 
Indiana Department of Revenue. 
Mailing Address 	
Drop 	

off Address 
Indiana Department of Revenue  Indiana Department of Revenue 
PO Box 6197 	
1	

00 North Senate Avenue 
Indianapolis, Indiana 46206 	
R	

oom N-105 
(317) 233-4015 Option 6 	
I	

ndianapolis, Indiana 46204 
The name of the corporation or limited liability company  on the Application for Reinstatement (State Form 4160), 
Affidavit for Reinstatement (State Form 49514)  and the Certificate of Clearance must be identical to the name on 
the records of our office, as provided on orig inal Articles of Incorporation (or Organization). 
STEP 2  Wait for the Certificate of Clearance to be mailed to you by the Department of Revenue. 
ƒ Please allow at least four (4) weeks for proc	
essing.	
STEP 3  Co

mplete the Application for Reinstatement (State Form 4160). 
STEP 4  Complete the Business Entity Report (State Form 48725)  and pay the filing fees for all the years owed. The 
filing fees are $15.00 per year  for all for-profit entities and $10.00 per year for nonprofit entities . It is not necessary 
to complete separate forms for each filing year,  as long as the filing fee for each year owed is paid and the most 
current  information is provided. 
ƒ All sections must be completed on both document	
s.	
ƒA si	

gnature is required on both documents	
.	
To 

determine amount due, please call (317) 232-6576 or visit  www.IN.gov/sos	
. 
STEP 5  Mail or hand deliver ALL of the following items together: 
1) Certificate of Clearance from Department of Revenue
2) Application for Reinstatement (State Form 4	
160)	
3) Business Entity Report (State Form 48725)
4) A check or money order payable to the Secretary of
 State for the filing fees to the following address:
Secretary of State, Corporations Division 
302 W. Washington Street, Room E-018 
Indianapolis, Indiana 46204 
ƒ Filing Fees –  The filing fee consists of all fees owed for business entity reports plus the Reinstatement fee
of $30.00. 
ƒ Call the information line for help determining the correct fees (317) 232-6576.
ƒ Visit our website at  www.IN.gov/sos	
 for answers to your questions	.	
ƒDo no	

t mail anything to the Secretary of State until you  have obtained the Certificate of Clearance from th	
e	
Depa	

rtment of Revenue.
ƒ All four items listed in step 5 must be mailed	
 TOGETHER.	
ƒ	Make check or money order payable to the Secretary of State.  Do not send cash.

Indiana Department of Revenue	
Affi davit for Reinstatement of Domestic Corporation	
State of Indiana    )
    ) SS
County of _______________ )
_________________________________________________ being duly sworn according to law, affi rms that he/she is the
   	
(name)	
___________________________________________ of _______________________________ a corporation organized
  	(offi cial capacity) 	    	(corporation name)	
under the laws of the State of Indiana, _____________________________ , with its principal offi ce located at address   
    	  (incorporation date)	
____________________________________________________ , city ________________________ , state _________ ,
zip _______________ , and identifi ed by Federal ID #______________________________ , and  Indiana sales and/or 
withholding tax TID # _______________________________ and that he/she makes this affi davit 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 fi led with the Indiana Department of Revenue and that all tax has been paid. The latest Indiana sales and/or 
withholding tax return were fi led for the month/year _____/_____ , under the name of ___________________________ .
            	
(name)	
That this affi davit 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.	
AD-19State Form 49514
(R3/ 10-10)

Correct / Change of 
Responsible Of fi cer Information	
This form is available in a PDF ‘ fi llable’ format; however, it cannot be submitted electronically, 
it must be printed, signed and mailed to the address below.
This form can be used to report any changes in the responsible of fi cers for your business.   Note:  You cannot use this 
form if the Internal Revenue Service has required you to obtain a new Fe\
deral Identi fi cation Number.  A change in Fed-
eral Identi fi cation Number requires a new registration with the Indiana Department Of\
 Revenue. 	
Business Information	
 Federal Identi fi cation Number (FEIN)  Indiana Taxpayer Identifi cation Number (TID)
Legal Name of the Entity 
Doing Business  As Name (DBA)
Street  Address  City State  Zip Code	
Old Responsible Offi cer Information	
Social Security No.  Last Name, First Name, Middle Initial, Suf fi x  Title     Address  City  State  Zip Code  Effective Date	
New Responsible Offi  cer Information	
Social Security No.  Last Name, First Name, Middle Initial, Suf fi x  Title     Address  City  State  Zip Code   Begin Date
I affi  rm that the changes provided are correct:  
Signature of the Person Submitting Changes:  Phone:
Printed Name of the Person Submitting Changes:  Title: Date: Note:  This agency is requesting the disclosure of your Social Security \
Number in accordance with IC 4-1-8-1.  
Disclosure is mandatory, this record cannot be processed without it.
Questions regarding the completion of this form may be directed to the I\
ndiana Department of Revenue at 317-233-4015
 or 317-232-0129 
                             
Mail the completed form to:  Indiana Department of Revenue, Tax Administration  P.O. Box 6197, Indianapolis, IN  46206-6197	
ROC-1 	State Form 52039 (R2/ 10-07)	
 start:    /    end:

INSTRUCTIONS	
Correct/Change of Responsible Offi cer Information
NOTICE:  All information, including the supporting documentation, must be provide\
d 
before the form will be considered to be a valid request.
If more space is needed to record your changes, you may attach a separat\
e sheet.
Business Information Section
Please provide the following required information: 1.  Federal (FEIN) and Indiana (TID) Identi fi cation Numbers
2.  Legal names of the entity submitting the change request
3.  DBA (Doing Business As) Name of the entity 	
(if different from the legal name)	
4.  Business mailing address
Old Responsible Of fi cer Information
Complete all applicable columns.  This information is necessary to ensure we identify and 
remove the correct individual.  
Note:  Supporting documentation establishing a separation date must be provid\
ed.   
Documentation may include: Corporate Minutes, Registration Letter, Financial Documents 
showing removal as a signatory of bank account, Af fi davit from another offi  cer; etc...
New Responsible Of fi cer Information
Complete all applicable columns.  This information is necessary to ensure we correctly 
identify and add the new of fi cer.
Note:  Supporting documentation must be provided.  Documentation may include:\
  Cor-
porate Minutes, Financial Documentation showing the addition of individu\
al as Signatory 
of  Bank Account, Affi  davit from another offi  cer; etc...
This change/correction must be submitted and signed by an existing owner\
, partner 
or corporate offi  cer before it will be accepted by the Department.
Note:  The individual submitting this change form request cannot be the person \
to be 
deleted as a responsible of fi cer.

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