Statement of Discontinuance, Change of Residence, Change
Location of Business, Withdrawal, or Deceased from Business
or Partnership.(In conformity with the provisions of Chapter 110,
Section 5 of the Massachusetts General Laws)
After the withdrawal / change is completed, if the business is
planning to continue to operate in Waltham, it is necessary to file a new Business Certificate.
Name of Business: ___________________________________________________________
Business Address: ______________________________________________________________
Filing Date: ___________________
Name of registered owner(s): ________________________________________________________
Addresses: ___________________________________________________________________
The following applies to the above named certificate:
Discontinued
Withdrawn from (i.e. owner’s name change business address or home address change)
The location of the business has changed to _______________________________________
My residence as it appears on the business certificate has changed to: ___________________
______________________________________________________________________________
Executor / Administrator Discontinuance of business certificate – Change of ownership from the
above-named to the following: __________________________________________
New owner’s Address: _________________________________________________
Executor / Administrator Withdrawal of the name of _____________________
who died on ________________from the business certificate
Signatures:.
___________________________________ _________________________
___________________________________ _________________________
On _________________the above named person(s) personally appeared before me and made oath
that the foregoing statement is true.
Identification Presented: Drivers License __________ Other ___________ City Seal:
___________________________________
Notary Public
Commission Expiration Date _______________________________
Notary Seal