Fillable Printable Penalty Fee Waiver Request
Fillable Printable Penalty Fee Waiver Request
Penalty Fee Waiver Request
Penalty Waiver RequestWashington 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 officeof 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 NameDate Phone
(All waiver requests will become public record when filed)
This Box For Office Use Only
Tracking ID Number:
