Indiana Affidavit for Reinstatement of Foreign Corporation

Affidavit for Reinstatement of Foreign Corporation
Form AD-19(2)
AD-19 (2)

Indiana Department of Revenue

State Form 49707
(R7 / 9-20)

Affidavit for Reinstatement of Foreign 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 _______________________, ________/______/______ ,
(incorporation date)

authorized to do business in the State of Indiana, _______/_____/______ with its principal office located at address
(date authorized)

_______________________________, county _______________, city ________________________ , state _________,
ZIP_____________ , and identified by Federal Employer Identification Number ______________________________,
and Indiana sales / withholding tax account number (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 of
(address)

______________________________. That this corporation is engaged in the business of _____________________
(name)

(primary purpose)

__________________________________. 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 filed with the Indiana
Department of Revenue and that all tax has been paid. The last Indiana income tax return was filed for year ending
_____/_____. The latest sales and/or withholding tax return(s) were filed on for period ending _____/______ , under
(month) (year)

(month) (year)

___________________________________________. That this affidavit is made for the sole purpose of inducing the
(name)

Indiana Department of Revenue to issue a notice, as provided under the applicable taxing acts, to the effect that such
corporation has paid all taxes due which will permit the Indiana Secretary of State to reinstate the corporation to active
status as authorized to do business in the State of Indiana.

									_____________________________________
									Signature

									_____________________________________
									Title
									_____________________________________
									Date

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