Secretary of State OFFICE OF SECRETARY OF STATE CORPOR A TIONS DIVISION 2 Martin Luther King Jr. Dr. SE Suite 313 West Tower Atlanta, Georgia 30334 (404) 656 - 2817 APPLICATIO N FO R WITHDRAWAL OF CERTIFICAT E O F AUTHORITY 1. Entity T y pe (ch e ck one only) : Corpor a t i o n Limited Liabili t y Compa n y Limited Partner s hip /Limited Liability Limited Partnership Limited Liabili t y Partnership Entity Control N umber : 2. Enti t y Name : 3. Home St a te / Cou n t r y ( St a te/Country in wh i c h entity w a s form e d ) : 4. The ent i t y s e lected in it e m 1 and named in item 2 no longer tr a nsa c ts busi n ess in Geor g ia and surre n ders its certifi c ate of authori t y . 5. The ent i t y r e v okes the authority of its regist e red a gent to ac ce pt ser v i ce of process o n its behalf an d appoints the Secret a r y of State o f G e orgia as its a gent for ser v i ce in a n y p r oceeding ba sed on a ca u se of a c tion th a t arose d uri n g the time it w a s a u thor i z ed to t r ans a ct busin e ss in Georgia. 6. A n y process ser v ed on the entity after w i thd r a w a l from Geor gi a m a y be mailed to the foll o w i ng addre s s: 7. The w i th d r a w i n g e ntity commits th a t it w i ll noti f y the Secr e ta r y of State of a n y changes in the mailing addre s s pr ov ided in item 6. 8. Signa t ure Date Print Name ( c h eck one only) : Corp o ration: Officer Chairperson of Board of Directors Receiver or Trustee Attorney - in - fact LLC: Member Ma n a g er Receiver or T rustee Attorney - in - fact LP /LLLP : Authorized Person LLP: Authorized Person Plea s e mail completed application to the address provi d ed at the top of t his form. Certificate of w ithdr a wal w ill be emailed t o the email add r ess provided bel o w . Email Address : F orm C D 555 (Rev. 6/2019 ) American LegalNet, Inc. www.FormsWorkFlow.com