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 Cancellation of Reserved Name (Domestic and Foreign Entity) CCR __________________________________________________________________________________________ Pursuant to the provisions of KRS 14A, KRS 271B, 273, 275, 362 and 386 the undersigned applies to cancel a reserved name and, for that purpose, submits the following statement: 1. The name reserved was _________________________________________________________________________. (Name must be identical to the name on record with the Secretary of State.) 2. The name was reserved by_______________________________________________________________________. 3. The date the name reservation was filed with the Office of the Secretary of State_____________________________. 4. The mailing address of the applicant: ____________________________________________ __________________________ ____________ _____________. Street Address or Post Office Box Numbers City State Zip 5. 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 Applicant Printed Name Title Date (01/12) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS CANCELLATION OF RESERVED NAME 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 applicant address. If the applicant wishes for the document to be sent to an alternate address other than the applicant address, 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 the applicant. NUMBER OF COPIES If filing via mail or in person, one exact copy of the document with the filing fee must be submitted to the address below. To make a copy of the filing for delivery to the local county clerk's office, visit www.sos.ky.gov and print a copy from the organization search tool. 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. A delayed th effective date may not be later than the 90 day after the date of filing. FILING FEE The filing fee for this document is $10.00. Checks should be made payable to the "Kentucky State Treasurer." MAILING ADDRESS Alison Lundergan Grimes Office of the Secretary of State PO Box 718 Frankfort, KY 40602-0718 OFFICE LOCATION Room 154, Capitol Building 700 Capital Avenue Frankfort, KY 40601 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. (01/12) American LegalNet, Inc. www.FormsWorkFlow.com