Fillable AD-19 Adavit for Reinstatement of Domestic Corporation (State of Indiana)

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AD-19 Adavit for Reinstatement of Domestic Corporation (State of Indiana)

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Indiana Department of Revenue
Adavit for Reinstatement of Domestic Corporation
_________________________________________________ being duly sworn according to law, arms under penalty of
of perjury that he/she is the ___________________________________________ _______________________________
a corporation organized under the laws of the State of Indiana, , with its principal _____________________________
, county , oce located at address ____________________________________________________ ________________
, and identied by Federal Employer , ZIP, state city ________________________ _________ _______________
, and Indiana sales and/or withholding tax TID # Identication Number______________________________
_______________________________ and that he/she makes this adavit for and on behalf of this corporation. He/She
, in care states that the books and records of this corporation are kept at _______________________________________
, and that this corporation is engaged in the business ofof ________________________________________
. To the best of my belief and knowledge, all of the said corporation’s __________________________________________
Indiana taxable income received on and after May 1, 1933, has been included in Indiana income tax returns led with the
Indiana Department of Revenue and that all tax has been paid. The latest Indiana sales and/or withholding tax return were
./led for the month/year , under the name of _____ _____ __________________________________
That this a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 eect 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
_____________________________________
Date
Mail to: Indiana Department of Revenue, Titles & Clearances Division, P.O. Box 6197, Indianapolis, IN 46206-6197.
(name)
(corporation name)
AD-19
State Form 49514
(R5 / 4-20)
(ocial capacity)
(incorporation date)
(address)
(name)
(primary purpose)
(name)
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AD-19 Adavit for Reinstatement of Domestic Corporation (State of Indiana)

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Completed 20 July 2020

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