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STATE OF CALIFORNIA

FRANCHISE TAX BOARD


P.O. BOX 942857
Application for Certificate
SACRAMENTO, CA 94257-2021 of Revivor

Before the Franchise Tax Board of the State of California

In the Matter of the Application for Certificate of Revivor of:


Corporate Number :
Corporate Name :
Address :

I REQUEST THAT THIS CORPORATION be reinstated from suspension or forfeiture. All required
payments, returns or documents have been previously submitted or are enclosed.

Only exempt organizations suspended pursuant to Section 23775 of the Revenue and Taxa-
tion Code must include a $10.00 revivor fee.
Print Name Title
Signature Date
Daytime Phone Number

Any stockholder or creditor or a majority of the surviving trustees or directors, officers or any other person having an
interest in the relief from suspension may sign on behalf of a bank or corporation.

Any officer, stockholder, creditor or any other person having an interest in the relief from forfeiture may sign on behalf
of a foreign bank or corporation.

TELEPHONE ASSISTANCE
Our regular toll-free telephone service is available from 7:00 a.m. until 8:00 p.m. Monday through Friday from the first working day in January through
the last filing day (generally April 15). The best times to call are between 7:00 and 10:00 in the morning and between 6:00 and 8:00 in the evening.
Service is also available from 8:00 a.m. through 5:00 p.m. on the two Saturdays prior to the final filing date. After April 15, service is available Monday
through Friday, between 8:00 a.m. and 5:00 p.m.
From within the United States, call . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-852-5711
From outside the United States, call (not toll-free) . . . . . . . . . . . . . . . . . . . 1-916-845-6500
For hearing impaired with TDD, call . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-822-6268

FTB 3557 (REV 9-95)