CA 53-02 CONTACT: KANSAS SECRETARY OF STATE Foreign Limited Liability Company Cancellation of Authority to do Business in Kansas Kansas Office of the Secretary of State Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 i (785) 296-4564 kssos@sos.ks.gov www.sos.ks.gov Above space is for office use only. All information must be completed or this document will not be accepted for filing. Please read instructions before completing. INSTRUCTIONS: 1. Business entity ID number: This is not the Federal Employer ID Number (FEIN) _______________________________________ 2. Name of limited liability company: Name must match the name on record with the Secretary of State ________________________________________________________________________________________ 3. Service of process may be forwarded to the limited liability company ________________________________________________________________________________________ Street Address at the following address: Name Address must be a street address. ______________________________________________________________________________________ A P.O. box is unacceptable City State Zip 4. The above-named foreign limited liability company registered to do business in the state of Kansas pursuant to Kansas law, hereby cancels its registration. 5. I/We declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct and that I/we have remitted the required fee. ________________________________________________________ _______________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Signature of member Date (month, day, year) Signature of member Signature of member Date (month, day, year) Date (month, day, year) Signature of member Signature of member Signature of member Date (month, day, year) Date (month, day, year) Date (month, day, year) Save time and money by filing your cancellation online at www.sos.ks.gov i Instructions: 1. If this form is submitted after the close of the entity’s tax year, an annual report and fee must be submitted along with or prior to cancellation. If the entity has forfeited, it must reinstate before cancellation. 2. Submit this form with the $35 filing fee. STAY UP-TO-DATE ON YOUR ORGANIZATION’S STATUS, ANNUAL REPORT DUE DATE AND CONTACT ADDRESSES BY GOING TO WWW.SOS.KS.GOV. UNDER QUICK LINKS, SELECT SEARCH BUSINESS ENTITY INFORMATION. There is a $25 service fee for all checks returned by your financial institution. All information must be completed or this document will not be accepted for filing. NOTICE: Rev. 12/27/10 jdr Page 1 of 1 K.S.A. 17-76,125 American LegalNet, Inc. www.FormsWorkFlow.com