BCS/CD-761 (Rev. 11/11) MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMERCIAL SERVICES (FOR BUREAU USE ONLY) Date Received This document is effective on the date filed, unless a subsequent effective date within 90 days after received date is stated in the document. Name Address City State Zip Code Document will be returned to the name and address you enter above. If left blank document will be mailed to the registered office. EFFECTIVE DATE: APPLICATION FOR CERTIFICATE OF WITHDRAWAL For use by Foreign Limited Liability Companies (Please read information and instructions on reverse side) Pursuant to the provisions of Act 23, Public Acts of 1993, the undersigned corporation executes the following Application: 1. The name of the limited liability company is: 2. The identification number assigned by the Bureau is: 3. It is organized under the laws of 4. The limited liability company is not transacting business in Michigan. 5. The limited liability company hereby surrenders its authority to transact business in Michigan. 6. The limited liability revokes the authority of its resident agent to receive service of process in this state and consents that service of process in any action, suit, or proceeding based upon any cause of action arising in this state during the time the foreign limited liability company was authorized to transact business in this state may thereafter be made on the company by service upon the administrator. 7. The address to which the administrator is to mail a copy of any process against this limited liability company is: (Name) (Street Address) (City) Signed this (State) (ZIP Code) , day of By (Signature) (Type or Print Name) (Type or Print Title) American LegalNet, Inc. www.FormsWorkFlow.com BCS/CD-761 (Rev. 11/11) Preparer's Name Business telephone number ( ) INFORMATION AND INSTRUCTIONS 1. The application for Certificate of Withdrawal cannot be filed until this form, or a comparable document is submitted. 2. Submit one original of this document. Upon filing, the document will be added to the records of the Bureau of Commercial Services. The original will be returned to your registered office address, unless you enter a different address in the box on the front of this document. Since this document will be maintained on electronic format, it is important that the filing be legible. Documents with poor black and white contrast, or otherwise illegible, will be rejected. 3. This Application is to be used pursuant to section 1006 of Act 23, P.A. of 1993, for the purpose of withdrawing a limited liability company's Certificate of Authority to Transact Business in Michigan. Upon filing of this Application, the limited liability company surrenders its its Certificate of Authority to Transact Business in this state. 4. Item 2 - Enter the identification number assigned by the Bureau. If this number is unknown, leave it blank. 5. This Application must be signed by a person with authority to sign as provided in the laws of the jurisdiction of its organization. 6. The limited liability company must request a tax clearance within 60 days after submitting this certificate from the Michigan Department of Treasury, Tax Clearance Division, Lansing, Michigan 48922, (517) 636-5260. 7. NONREFUNDABLE FEE: Make remittance payable to the State of Michigan. Include limited liability company name and identification number on check or money order.................................................................................................................................$10.00 Submit with check or money order by mail: Michigan Department of Licensing and Regulatory Affairs Bureau of Commercial Services Corporation Division P.O. Box 30054 Lansing, MI 48909 To submit in person: 2501 Woodlake Circle Okemos, MI Telephone: (517) 241-6470 Fees may be paid by check, money order, VISA or Mastercard when delivered in person to our office. MICH-ELF (Michigan Electronic Filing System) First Time Users: Call (517) 241-6470, or visit our website at http://www.michigan.gov/corporations Customer with MICH-ELF Filer Account: Send documents to (517) 636-6437 LARA is an equal opportunity employer/prgram. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. American LegalNet, Inc. www.FormsWorkFlow.com Optional expedited service. Expedited review and filing, if fileable, is available for all documents for profit corporations, limited liability companies, limited partnerships and nonprofit corporations. The nonrefundable expedited service fee is in addition to the regular fees applicable to the specific document. Please complete a separate BCS/CD-272 form for expedited service for each document submitted in person, by mail or MICH-ELF. 24-hour service - $50 for formation documents and applications for certificate of authority. 24-hour service - $100 for any document concerning an existing entity. Same day service Same day - $100 for formation documents and applications for certificate of authority. Same day - $200 for any document concerning an existing entity. Review completed on day of receipt. Document and request for same day expedited service must be received by 1 p.m. EST OR EDT. Two hour - $500 Review completed within two hours on day of receipt. Document and request for two hour expedited service must be received by 3 p.m. EST OR EDT. One hour - $1000 Review completed within one hour on day of receipt. Document and request for 1 hour expedited service must be received by 4 p.m. EST OR EDT. First time MICH-ELF user requesting expedited service must obtain a MICH-ELF filer number prior to submitting a document for expedited service. BCS/CD-901. Changes to information on MICH-ELF user's account must be submitted before requesting expedited service. BCS/CD-901. Documents submitted by mail are delivered to a remote location for receipts processing and are then forwarded to the Corporation Division for review. Day of receipt for mailed expedited service requests is the day the Corporation Division receives the request. Rev. 5/10 American LegalNet, Inc. www.FormsWorkFlow.com