APPLICATION FOR CANCELLATION BY FOREIGN LIMITED LIABILITY COMPANY (PLEASE TYPE OR PRINT CLEARLY IN INK) The undersigned, pursuant to Act 1003, sets forth the following: 1. Foreign Limited Liability Company Name: ___________________________________________________________ _____________________________________________________________________________________________ 2. State of Organization: ___________________________________________________________________________ 3. The Foreign Limited Liability Company is not transacting business in this State and hereby surrenders its authority to do so. 4. The Foreign Limited Liability Company revokes the authority of its registered agent to accept service on its behalf and appoints the Secretary of State as its agent for service of process in any action, suit or proceeding based on a cause of action arising during the time it was authorized to transact business in this State. The Arkansas Secretary of State shall hereafter be the authorizing recipient of service for valid service of process on this Foreign Limited Liability Company. 5. The Foreign Limited Liability Company’s mailing address for any service of process pursuant to paragraph four is: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days. Executed this ____________________ day of _____________________, ____________________________. __________________________________________________ ____________________________________________ Authorizing Officer and Title (Type or Print) NO FEE Authorized Signature FL-04 Rev. 08/07 American LegalNet, Inc. www.FormsWorkFlow.com