APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF A FOREIGN LIMITED LIABILITY COMPANY CONNIE LAWSON SECRETARY OF STATE CORPORATIONS DIVISION 302 W. Washington Street, Room E018 Indianapolis, Indiana 46204 Telephone: (317) 232-6576 State Form 49461 (R2 / 4-12) Approved by State Board of Accounts, 1999 INSTRUCTIONS: Use 8 1/2" x 11" white paper for inserts. Present original and two (2) copies to address in upper right corner of this form. Please TYPE or PRINT. Upon completion of filing the Secretary of State will issue a receipt. Indiana Code 23-18-11-13 FILING FEE IS $30.00 APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF Name of Limited Liability Company A FOREIGN LIMITED LIABILITY COMPANY ADMITTED TO TRANSACT BUSINESS IN THE STATE OF INDIANA The undersigned manager or member of the above, _________________________________________________________ LLC (hereinafter referred to as the "LLC"), which exists pursuant to the provisions of ____________________________________ as (state or country) amended, desiring to effectuate the withdrawal of the LLC from the State of Indiana, certifies the following facts: ARTICLE I - NAME Name of LLC State or country in which it is organized ARTICLE II - REPRESENTATION BY THE WITHDRAWING LLC The LLC received its Certificate of Authority from the State of Indiana on _______________________________________ and is no longer transacting business in Indiana. The LLC surrenders its authority to transact business in Indiana. ARTICLE III - SERVICE OF PROCESS The LLC revokes the authority of ________________________________________________________________________, its Registered Agent to accept service of process on its behalf and appoints the Secretary of State as its agent for service of process in any proceeding based on a cause of action arising during the time it was authorized to transact business in Indiana. A copy of any such process served on the Secretary of State should be mailed to the following address of the LLC: Address of LLC (number and street, city, state, and ZIP code) The Limited Liability Company shall notify the Secretary of State in the future of any change in its mailing address. In witness whereof, the undersigned being the ______________________________________________________________ of (Manager or member) said LLC executes this Application for Certificate of Withdrawal and verifies, subject to penalties of perjury, that the statements contained herein are true this ___________ day of ____________________________________ , __________. Signature Printed name American LegalNet, Inc. www.FormsWorkFlow.com