Indiana Affidavit for Reinstatement of Domestic Corporation

Affidavit for Reinstatement of Domestic Corporation
Form AD-19
AD-19

State Form 49514
(R7 / 9-20)

Indiana Department of Revenue

Affidavit for Reinstatement of Domestic Corporation

_________________________________________________ being duly sworn according to law, affirms under penalty of
(name)

perjury that he/she is the ___________________________________________ of _______________________________
(official capacity)

(corporation name)

a corporation organized under the laws of the State of Indiana, _____________________________ , with its principal
(incorporation date)

office located at address ____________________________________________________ , county ________________,
city ________________________ , state _________ , ZIP _______________ , and identified by Federal Employer
Identification Number______________________________, and Indiana sales and/or withholding tax TID #
_______________________________ and that he/she makes this affidavit for and on behalf of this corporation. He/She
states that the books and records of this corporation are kept at _______________________________________ , in care
(address)

of ________________________________________, and that this corporation is engaged in the business of
(name)

__________________________________________. To the best of my belief and knowledge, all of the said corporation’s
(primary purpose)

Indiana taxable income received on and after May 1, 1933, has been included in Indiana income tax returns filed with the
Indiana Department of Revenue and that all tax has been paid. The latest Indiana sales and/or withholding tax return were
filed for the month/year _____/_____ , under the name of __________________________________.
(name)

That this affidavit 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
									_____________________________________
									Date

Mail to: Indiana Department of Revenue, Titles & Clearances Division, P.O. Box 6072, Indianapolis, IN 46206-6072.