Document processing fee If document is filed on paper $10.00 If document is filed electronically Currently Not Available Fees & forms/cover sheets are subject to change. To access instructions for this form/cover sheet and other information or to print copies of filed documents, visit www.sos.state.co.us and select Business. Paper documents must be typewritten or machine printed. ABOVE SPACE FOR OFFICE USE ONLY Statement of Change Withdrawing a Registration of True Name filed pursuant to §7-90-305.5 and §7-90-604 of the Colorado Revised Statutes (C.R.S) 1. The ID number and the true name are ID number _________________________ (Colorado Secretary of State ID number) True name ______________________________________________________. 2. The registration of true name is relinquished. 3. (If applicable, adopt the following statement by marking the box and include an attachment.) This document contains additional information as provided by law. 4. (Caution: Leave blank if the document does not have a delayed effective date. Stating a delayed effective date has significant legal consequences. Read instructions before entering a date.) (If the following statement applies, adopt the statement by entering a date and, if applicable, time using the required format.) The delayed effective date and, if applicable, time of this document is/are __________________________. (mm/dd/yyyy hour:minute am/pm) 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 such document is such individual's act and deed, or that such individual in good faith believes such document is the act and deed of the person on whose behalf such individual is causing such document to be delivered for filing, taken in conformity with the requirements of part 3 of article 90 of title 7, C.R.S., and, if applicable, the constituent documents and the organic statutes, and that such individual in good faith believes the facts stated in such document are true and such 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 identified in this document as one who has caused it to be delivered. WTDRW_TRUE Page 1 of 2 Rev. 12/01/2009 American LegalNet, Inc. www.FormsWorkFlow.com 5. The true name and mailing address of the individual causing this document to be delivered for filing are ____________________ ______________ ______________ _____ (Last) (First) (Middle) (Suffix) ______________________________________________________ (Street number and name or Post Office Box information) ______________________________________________________ __________________________ _____ (City) (State) ____________________ (ZIP/Postal Code) _______________________ ______________________________ (Province – if applicable) (Country) (If applicable, adopt the following statement by marking the box and include an attachment.) This document contains the true name and mailing address of one or more additional individuals causing the document to be delivered for filing. Disclaimer: This form/cover sheet, and any related instructions, are not intended to provide legal, business or tax advice, and are furnished without representation or warranty. While this form/cover sheet 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/cover sheet. Questions should be addressed to the user’s legal, business or tax advisor(s). WTDRW_TRUE Page 2 of 2 Rev. 12/01/2009 American LegalNet, Inc. www.FormsWorkFlow.com Mail form with correct payment to: Colorado Secretary of State 1700 Broadway Ste 200 Denver, CO 80290 Make checks payable to: Colorado Secretary of State Include a separate check for each form submitted for filing. If a document is rejected, this will allow us to return the check at the time of rejection (if applicable). The document can be corrected and resubmitted with the returned check. Checks must be written for the exact amount or the document may be rejected and returned. Do not include this page with your filing. American LegalNet, Inc. www.FormsWorkFlow.com