ALL INFORMATION MUST BE COMPLETED BEFORE RECORDING DISSOLUTION OF ASSUMED BUSINESS NAME ORIGINAL REFERENCE NO. ________________ For individuals, (sole proprietorships), Firms, Partnerships or Limited Liability Companies engaged in business under a name other than their own STATE OF INDIANA, COUNTY OF ST. JOSEPH Name of Business: ________________________________________________ Kind of Business: _________________________________________________ Address of Business: ______________________________________________ Street, City, State and Zip Code Printed names & complete residence addresses of members of business: ________________________ at _______________________________________ ________________________ at _______________________________________ ________________________ at _______________________________________ ________________________ at _______________________________________ I hereby certify that I have personal knowledge of the facts stated above and that each of them are true. __________________________ __________________________ __________________ Signature Printed Name Capacity of Signer Form prepared by: ________________________________________________________ Print name This completed form must be filed in the office of the County Recorder of each county in which a place of business or office is located. __________________________ Date of Document ____________________________________ Recorder’s Signature & Seal I affirm under the penalties for perjury, that I have taken reasonable care to redact each Social Security number in this document, unless required by law (name) American LegalNet, Inc. www.FormsWorkflow.com _____________________________________________________________