COMMONWEALTH OF KENTUCKY ALISON LUNDERGAN GRIMES, SECRETARY OF STATE _________________________________________________________________________________________________________________________ Division of Business Filings Business Filings PO Box 718 Frankfort, KY 40602 (502) 564-3490 www.sos.ky.gov Certificate of Withdrawal of Assumed Name (Domestic or Foreign Business Entity) CWA ______________________________________________________________________________________ Pursuant to the provisions of KRS 365, the undersigned applicant applies to withdraw an assumed name and, for that purpose, submits the following statements: 1. The assumed name to be withdrawn is ______________________________________________________________. (The name must be identical to the name on record with the Secretary of State.) 2. The assumed name has been discontinued by_________________________________________________________. (Must be the exact name of the entity or partners) 3. This application will be effective upon filing, unless a delayed effective date and/or time is provided. The effective date or the delayed effective date cannot be prior to the date the application is filed. The date and/or time is ______________. (Delayed effective date and/or time) 4. The date the original certificate as filed: ______________________________________________________________. 5. The "real name" is (you must check one): _____a Domestic General Partnership _____a Domestic Limited Liability Partnership _____a Domestic Limited Partnership _____a Domestic Business Trust _____a Domestic Corporation _____a Domestic Limited Liability Company 6. The mailing address is: ____________________________________________ __________________________ ___________________ ______ Street Address or Post Office Box Numbers City State Zip _____a Foreign General Partnership _____a Foreign Limited Liability Partnership _____a Foreign Limited Partnership _____a Foreign Business Trust _____a Foreign Corporation _____a Foreign Limited Liability Company I declare under penalty of perjury under the laws of Kentucky that the forgoing is true and correct. _________________________________________ ________________________ _________________ ______ Signature of Authorized Party Printed Name Title Date (01/12) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS CERTIFICATE OF WITHDRAWAL OF ASSUMED NAME ASSUMED NAME The certificate must state the assumed name under which business will be conducted or transacted. The assumed name must be a name that is distinguishable upon the records of the Secretary of State from any other name previously filed and on record with the Secretary of State. A separate certificate must be filed for each assumed name that is being adopted by the business. KRS 365.015(3) requires the certificate of assumed name for an individual (sole proprietorship) to be filed with the county clerk where the person is deemed a resident for the purposes of and under the provisions of KRS Chapter 355. An assumed name registration is effective for a term of five (5) years from the date it is filed with the Secretary of State and may be renewed for a successive term upon filing a renewal certificate. A renewal certificate must be filed with the Secretary of State within six (6) months prior to the expiration date. A renewal certificate filed with the Secretary of State renews the assumed name for a five-year term. The business entity should arrange its own reminder of the renewal deadline, since the Secretary of State is not required to send renewal certificates. Any certificate of assumed name in effect on July 15, 1998, shall continue in effect for five (5) years and may be renewed by filing a renewal certificate with the Secretary of State. REAL NAME The real name is defined as follows: The real name of a Domestic General Partnership is the name that includes the real name of each general partner; The real name of a Domestic Registered Limited Liability Partnership is the name stated in its statement of registered limited liability partnership filed pursuant to KRS Chapter 362; The real name of a Domestic Limited Partnership is the name stated in its Certificate of Limited Partnership filed pursuant to KRS 362; The real name of a Domestic Business Trust is the name set forth in its Declaration of Trust; The real name of a Domestic Corporation is the name set forth in its Articles of Incorporation; The real name of a Domestic Limited Liability Company is the name set forth in its Articles of Organization; The real name of a Foreign General or Limited Partnership and of a Foreign Business Trust is the name recognized by the laws of the foreign state under which it is formed as being the real name or the fictitious name adopted for use in this state; The real name of a Foreign Limited Liability Partnership is the name stated in its statement of foreign qualification filed pursuant to KRS 362.1 The real name of a Foreign Corporation is the name set forth in its Articles of Incorporation or the fictitious name adopted for use in this state under KRS 271B.15-060; or The real name of a Foreign Limited Liability Company is the name set forth in its articles of organization or the fictitious name adopted for use in this state under KRS 275.410. PRINCIPAL OFFICE ADDRESS The principal office is the office (in or out of this state) so designated in writing with the Office of the Secretary of State where the principal designated office of the business entity is located. This address is where all correspondence from the Office of the Secretary of State (See Document Delivery) will be mailed.. EFFECTIVE DATE AND TIME/DELAYED EFFECTIVE DATE AND TIME The document will be effective on the date and time of filing, unless a delayed effective date and/or time is specified. The effective date or the delayed effective date cannot be prior to the date the application is filed. A delayed effective date may not be later than the 90 th day after the date of filing. DOCUMENT DELIVERY A file stamped postcard will be sent to the principal office address. If the applicant wishes for the document to be sent to an alternate address other than the principal office, a request must be submitted in writing affirming that request. Alternate address requests must be submitted with each document filed with the Office of the Secretary of State. WHO MAY SIGN The document must be signed by: at least one partner authorized to do so by the partners of a Domestic or Fore