(1) The name of the corporation and the jurisdiction in which it is incorporated;

(2) That the corporation is not conducting affairs in this State;

(3) That the corporation surrenders its authority to conduct affairs in this State;

(4) That the corporation revokes the authority of its registered agent in this State to accept service of process and consents that service of process in any action or proceeding based upon any cause of action arising in this State during the time the corporation was authorized to conduct affairs in this State may thereafter be made on such corporation by service thereof on the director;

(5) The dates that notice of the foreign corporation's intent to withdraw from the State was published, once in each of four successive weeks (four publications) in a newspaper of general circulation published in the State. The foreign corporation, with the approval of the director, may omit the publication of the notice if the corporation has insufficient assets to pay for the publication;

(6) That all taxes, debts, obligations, and liabilities of the foreign corporation in the State have been paid and discharged or that adequate provision has been made therefor; and

(7) A post office address to which the director may mail a copy of any process against the corporation that may be served on the director.