COMMONWEALTH OF KENTUCKY ALISON LUNDERGAN GRIMES, SECRETARY OF STATE _________________________________________________________________________________________________________________________ Division of Business Filings Withdrawal of Filing Before Effectiveness WBE Business Filings (Domestic or Foreign Entity) PO Box 718 Frankfort, KY 40602 (502) 564-3490 www.sos.ky.gov _________________________________________________________________________________________________ Pursuant to the provisions of KRS 14A, 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 name of the document to be withdrawn___________________________________________________________. 3. The date the document was filed in Kentucky__________________________________________________________. 4. The document has been withdrawn in accordance with the agreement of the parties. 5.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 Authorized Agent Printed Name Date _________________________________________________________________________________________________ Signature of Authorized Agent Printed Name Date (01/12) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS WITHDRAWAL OF FILING BEFORE EFFECTIVENESS NAME Use the exact name of the business entity as registered on file with the Office of the Secretary of State. 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. 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 or a partner. 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 th 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 day after the date of filing. 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. 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. FILING FEE The filing fee for this document is equal to that of the filed document that is being withdrawn. Checks should be made payable to the "Kentucky State Treasurer." MAILING ADDRESS Alison Lundergan Grimes Office of the Secretary of State P.O. 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