(06/17) 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 Pursuant to the provisions of KRS 14A and KRS 271B, 273, 274, 275, 362 or 386 the undersigned applies for a certificate of withdrawal on behalf of the business entity named below and, for that purpose, submits the following statements: 1. The name of the business entity is . (The name must be identical to the name on record with the Secretary of State.) 2. The state or country of formation is . 3. The Secretary of State may forward to the business entity at the following street address any process served on the Secretary of State and commits to notify the Secretary of State of any future changes to this address: Street Address (No Post Office Box Numbers) City State Zip Code 4. The business entity is not transacting business in the Commonwealth and surrenders its authority to transact business in the Commonwealth or pursuant to KRS 14A.9-010(7) the business entity is a foreign insurer with a certificate of authority from the commissioner of the Department of Insurance. 5. The business entity 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 the Commonwealth. The business entity shall notify the Secretary of State in the future of any change in its mailing address. 6. 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) I declare under penalty of perjury under the laws of Kentucky that the forgoing is true and correct. Signature of Authorized Representative Printed Name Date Certificate of Withdrawal W FE ( Foreign Business Entity ) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS CERTIFICATE OF WITHDRAWAL OF A FOREIGN BUSINESS ENTITY NAME Use the exact name of the business entity as registered on file with the Office of the Secretary of State. 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 an officer, chairman of the board, member, manager, partner or trustee. NUMBER OF COPIES If filing via mail or in person, one exact or conformed copy of the documents with the filing fee must be submitted to the address below. organization search tool. 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 90th day after the date of filing. FILING FEE The filing fee for this document is $40.00. Checks should be made payable to the "Kentucky State Treasurer." MAILING ADDRESS OFFICE LOCATION Alison Lundergan Grimes Room 154, Capitol Building Office of the Secretary of State 700 Capital Avenue P.O. Box 718 Frankfort, KY 40601 Frankfort, KY 40602-0718 Hours of Operation: 8:00 AM-4:30 PM ET CONTACT INFORMATION If you have any questions, please feel free to visit our website at www.sos.ky.gov or call 502-564-3490. American LegalNet, Inc. www.FormsWorkFlow.com