Document processing fee If document is filed on paper $125.00 If document is filed electronically $ 25.00 Fees & forms/cover sheets are subject to change. To file electronically, access instructions for this form/cover sheet and other information or print copies of filed documents, visit www.sos.state.co.us and select Business Center. Paper documents must be typewritten or machine printed. ABOVE SPACE FOR OFFICE USE ONLY Statement of Dissolution filed pursuant to §7-90-301, et seq. and §7-80-802 of the Colorado Revised Statutes (C.R.S) ID number: _____________________ 1. Entity name: ______________________________________________________ 2. Principal office mailing address: ______________________________________________________ (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ ____________________ (City) (State) (Postal/Zip Code) _______________________ ______________ (Province – if applicable) (Country – if not US) 3. The limited liability company is dissolved. 4. (Optional) Delayed effective date: ______________________ (mm/dd/yyyy) Notice: Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the individual's act and deed, or that the individual in good faith believes the document is the act and deed of the person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic statutes, and that the individual in good faith believes the facts stated in the document are true and the document complies with the requirements of that Part, the constituent documents, and the organic statutes. This perjury notice applies to each individual who causes this document to be delivered to the secretary of state, whether or not such individual is named in the document as one who has caused it to be delivered. 5. Name(s) and address(es) of the individual(s) causing the document to be delivered for filing: ____________________ ______________ ______________ _____ (Last) (First) (Middle) (Suffix) ______________________________________________________ (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ ____________________ (City) (State) _______________________ (Province – if applicable) DISS_LLC (Postal/Zip Code) ______________ (Country – if not US) Page 1 of 2 Rev. 11/16/2005 American LegalNet, Inc. www.USCourtForms.com (The document need not state the true name and address of more than one individual. However, if you wish to state the name and address of any additional individuals causing the document to be delivered for filing, mark this box name and address of such individuals.) and include an attachment stating the Disclaimer: This form, and any related instructions, are not intended to provide legal, business or tax advice, and are offered as a public service without representation or warranty. While this form is believed to satisfy minimum legal requirements as of its revision date, compliance with applicable law, as the same may be amended from time to time, remains the responsibility of the user of this form. Questions should be addressed to the user’s attorney. DISS_LLC Page 2 of 2 Rev. 11/16/2005 American LegalNet, Inc. www.USCourtForms.com