REVOKE Page 1 of 2 Rev. 10 / 18 / 201 7 Document processing fee If document is filed on paper $150.00 If document is filed electronically Not available For more information or to print copies of filed documents, visit www.sos.state.co.us . Must be typewritten or machine printed. ABOVE SPACE FOR OFFICE USE ONLY Statement of Correction Revoking a Filed Document filed pursuant to 2477 - 90 - 305 of the Colorado Revised Statutes (C.R.S.) 1. For the entity, its ID number, entity name, and tr ue name, if applicable, are ID number (Colorado Secretary of State ID number) Entity name . True name . 2. The document number of the filed document being revoked is . 3. Adopt one of the following statements by marking the box: The filed document states a delayed effective date that is not yet effective and is revoked pursuant to section 7 - 90 - 304 (3), C.R.S. OR The filed document is revoked because it was delivered to the Secretary of State for filing in error. ( If applicable, adopt the following statement by marking the box and include an attachment.) 4 . This document contains additional information as provided by law. Notice: Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or acknow ledgment 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 individ ual 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 bel ieves 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. American LegalNet, Inc. www.FormsWorkFlow.com REVOKE Page 2 of 2 Rev. 10 / 18 / 201 7 This perjury notice applies to each individual who causes this document to be delivered t o the Secretary of State, whether or not such individual is identified in this document as one who has caused it to be delivered. 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 the following statement applies, adopt the 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 no t 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 ma y be amended from time to time, business or tax advisor(s). American LegalNet, Inc. www.FormsWorkFlow.com Business Information Survey (Optional) For office use only Submit with your form if you want to add , change , or remove survey information Survey information can be added, changed, or removed when you file a form with our office . - it does not become a part of the document that you file with us. Th is survey is voluntary. Any information that you enter will be available to the public. The information is being gat hered as required by law - see House Bill 13 - 1167 for information. Entity information ID number E ntity name Choose one: 1. Remove all survey information from this 2. Add or update the survey information on this a) Gender Male Female Choose not to answer / Remove this information b) Veteran? Yes No Choose not to answer / Remove this information c) Person with a disability? Yes No Choose not to answer / Remove this information d) Race African American Latino Anglo Native American Asian Other Choose not to answer / Remove this information SurveyInfo Page 1 of 2 Rev. 12/11/2013 American LegalNet, Inc. www.FormsWorkFlow.com Entity information continued e) NAICS code(s) Enter up to five. For more information, see the NAICS Association site at www.naics.com/search.htm. First Middle Last Suffix Address 1 Address 2 City State ZIP code Province Country information SurveyInfo Page 2 of 2 Rev. 12/11/2013 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.002 American LegalNet, Inc. www.FormsWorkFlow.com