FORM Payment may be made by check payable to Secretary of State. If check is returned for any reason this filing will be void. Secretary of State Department of Business Services Limited Liability Division 501 S. Second St., Rm. 357 Springfield, IL 62756 217-524-8008 www.cyberdriveillinois.com October 2014 UPA-704 Illinois Uniform Partnership Act Statement of Dissociation SUBMITINDUPLICATE Type or Print Clearly. $25 FILE #: This space for use by Secretary of State. Filing Fee: Approved: 1. Partnership Name: (Name must be stated exactly as on record with the Secretary of State.) 2. Check one: Partnership or Limited Liability Partnership 3. Federal Employer Identification Number: 4. Partner dissociated from partnership: The undersigned declares the above-named partner to be dissociated from the Partnership. The undersigned declares under the penalty of perjury, under the laws of the State of Illinois, that the foregoing is true, correct and complete. Executed on the Day of Month , Year by a partner. If filed by a dissociating partner, the dissociating partner must sign. Signature Number, Street Address Name and Title (type or print) City, State, Zip If filed by the partnership, a partner must sign. Signature Number, Street Address Name and Title (type or print) City, State, Zip Printed by authority of the State of Illinois. November 2014 - 1 - UPA 10.3 American LegalNet, Inc. www.FormsWorkFlow.com