Fillable Printable Penalty Fee Waiver Request

Penalty Fee Waiver Request

Penalty Waiver Request Washington Secretary of State Revised 04/15

Mail to: Division of Corporations & Charities

Attn: Waiver request

PO Box 40234, Olympia, WA 98504

Request for Waiver of Penalty Fees

(Note: filing fees cannot be waived or refunded)

□ Reinstatement Penalty Fee

□ Delinquency Fee / Late Filing Fee

Penalty Fee Waiver Request

Per RCW’s and WACs

NAME OF BUSINESS OR CHARITABLE ORGANIZATION MAKING REQUEST:

____________________________________________________________________________

(As recorded or as presented to the office of the Secretary of State)

UBI Number or Charities Registration Number:

MAILING ADDRESS OF ORGANIZATION OR INDIVIDUAL MAKING REQUEST:

Mailing Address ______________________________City___ __________State_____ Zip____________

Printed name of Individual _______________________ Email address of Individual_____________________

EXPLAIN THE ISSUE AND WHY THE REQUEST FOR WAIVER IS BEING SUBMITTED:

DATE OF DISCOVERY AND EXPLANATION: ____________________________________________________

PRINTED NAME AND SIGNATURE OF OFFICER/AUTHORIZED PERSON MAKING REQUEST:

This document is hereby executed under penalties of perjury, and is, to the best of my knowledge, true and correct.

X_______________________________________________________________________________________

Signature Printed Name Date Phone

(All waiver requests will become public record when filed)

This Box For Office Use Only

Tracking ID Number: