GP (For Office Use Only) COVER LETTER TO: Registration Section Division of Corporations SUBJECT: (Name of Partnership) DOCUMENT NUMBER: The enclosed Statement of Dissociation for Partnership and fee(s) are submitted for filing. Please return all correspondence concerning this matter to the following: (Name of Person) (Firm/Company) (Address) (City/State and Zip Code) For further information concerning this matter, please call: at ( (Name of Person) ) (Area Code & Daytime Telephone Number) STREET ADDRESS: Registration Section Division of Corporations Clifton Building 2661 Executive Center Circle Tallahassee, Florida 32301 CR2E071 (9/15) MAILING ADDRESS: Registration Section Division of Corporations P.O. Box 6327 Tallahassee, Florida 32314 American LegalNet, Inc. www.FormsWorkFlow.com STATEMENT OF DISSOCIATION FOR PARTNERSHIP Pursuant to section 620.8704, Florida Statutes, I hereby submit the following statement of dissociation: FIRST: The name of the partnership is: SECOND: (CHECK ONE) The partnership was registered with the Florida Department of State on and assigned registration number GP . The partnership has not registered with the Florida Department of State. THIRD: The purpose of this document is to state that (Partner's Name) has dissociated as a partner from . (Partnership Name) FOURTH: Effective date, if other than the date of filing: . (Effective date cannot be prior to the date of filing nor more than 90 days after the date of filing.) NOTE: If the date inserted in this block does not meet the applicable statutory filing requirements, this date will not be listed as the document's effective date on the Department of State's records. The execution of this statement in compliance with s. 620.8105(6) constitutes an affirmation under the penalties of perjury that the facts stated herein are true. I am aware that any false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s. 817.155, F.S Signed this _____ day of ____________________________, _______. (Signature) (Typed or printed name of person signing above) Filing Fee: Certified copy: Certificate of Status: $25.00 $52.50 (optional) $ 8.75 (optional) American LegalNet, Inc. www.FormsWorkFlow.com Make checks payable to Florida Department of State and mail to: Division of Corporations P.O. Box 6327 Tallahassee, FL 32314 American LegalNet, Inc. www.FormsWorkFlow.com