Massachusetts Corporation Reinstatement Following Administrative Dissolution Form

Massachusetts-based corporations subjected to administrative dissolution, specifically those that were dissolved after the 1st of July 2014, can apply for reinstatement through the filing of this form.Download

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FORM MUST BE TYPED	FORM MUST BE TYPED	
The Commonwealth of Massachusetts	
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512	
c156ds142295011347 01/13/05	P.C.
D
PC	
* The corporation must file annual reports for the previous ten (10) fiscal years, if not previously filed.	
Application For Reinstatement 
Following Administrative Dissolution	
(General Laws Chapter 156D, Section 14.22; 950 CMR 113.47)	
(1)  Exact name of corporation: 	 ________________________________________________________________________\
___	
(2)  Registered office address:	 ________________________________________________________________________\
_____	
  (number, street, city or town, state, zip code)
 Name of the registered agent at registered office:	 ___________________________________________________________	
(3)  Effective date of the corporation’s administrative dissolution:	 __________________________________________________	
  (month, day, year)
(4) The grounds for administrative dissolution:
  (check appropriate box)	
® did not exist.
® have been eliminated.	
(5)  The corporation’s name satisfies the requirements of G.L. Chapter 156D, Section 4.01 or the corporation shall simultaneously 	
submit a certificate of amendment to change its name to a name that satisfies th\
e requirements of G.L. Chapter 156D, Section 
4.01.	
(6) The reinstatement of the corporation shall be effective at the time and on the date approved by the Division, unless a later	 ef-
fective date not more than 90 days from the date and time of filing is specified:	
  ____________________________________	
(7)  Attach a certificate from the Commonwealth of Massachusetts Department of Revenue reciting that all corporate excise taxes 	
and any related penalties have been paid or a request to the Department of Revenue for this certificate.	
(8) The Division shall:
  (check appropriate box)	
® reinstate the corporation without limitation.*
® limit reinstatement to a specified period of time not to exceed one year.

Signed by: _____________________________________________________________________\
_______________________,
 (signature of authorized individual)	
® Chairman of the board of directors,
® President,
® Other officer,
® Court-appointed fiduciary,	
on this	 _________________________	day of_________________________________________ , 	 _____________________	.

Examiner  
Name approval   
#A.R.	
COMMONWEALTH OF MASSACHUSETTS	
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512	
Application for Reinstatement  
Following Administrative Dissolution	
(General Laws Chapter 156D, Section 14.22; 950 CMR 113.47)	
I hereby certify that upon examination of this application for reinstatement, duly submit -
ted to me, it appears that the provisions of the General Laws relative thereto have been 
complied with, and I hereby approve said application; and the filing fee in the amount 
of $______ having been paid, said application is deemed to have been filed with me this 
_____________ day of	
 ______________	20_______ at	 _______	a.m./p.m.	
  time
Effective date:  ____________________________________________	 ________	
  (must be within 90 days of date submitted)	
WILLIAM FRANCIS GALVIN	
Secretary of the Commonwealth
Filing fee: $100	
TO BE FILLED IN BY CORPORATION	
Contact Information:
___________________________________________________________
___________________________________________________________
___________________________________________________________
Telephone:	
  ___________________________________________________	
Email:	  ______________________________________________________	
Upon filing, a copy of this filing will be available at www.sec.state.ma.us/cor. 
If the document is rejected, a copy of the rejection sheet and rejected document will 
be available in the rejected queue.