Kentucky Secretary of State TREY GRAYSON ___________________________________________________________________________________________________________ Division of Corporations BUSINESS FILINGS P.O. Box 718 Frankfort, KY 40602 (502) 564-2848 http://www.sos.ky.gov/ Application for Certificate of Withdrawal FLW _______________________________________________________________________________ Pursuant to the provisions of KRS Chapter 275, the undersigned hereby applies for a Certificate of Withdrawal on behalf of the limited liability company named below and for that purpose submits the following statements: 1. The name of the limited liability company is _____________________________________________________________________________. (Name of limited liability company or fictitious name adopted for use in Kentucky) 2. The state or country of organization is _____________________________________________. 3. The limited liability company is not transacting business in Kentucky. 4. The limited liability company hereby surrenders its authority to transact business in Kentucky. 5. The limited liability company hereby revokes the authority of its registered agent in Kentucky to accept service of process on its behalf and hereby appoints the Secretary of State as its agent for service of process in any proceeding based upon any cause of action arising during the time it was authorized to transact business in Kentucky. 6. The mailing address to which the Secretary of State may mail a copy of any process served on the Secretary of State is _____________________________________________________________________________. Address City/State Zip Code 7. The limited liability company hereby commits to notify the Secretary of State in the future of any change in the mailing address in statement #6 (above). 8. This application will be effective upon filing, unless a delayed effective date and/or time is specified: ___________________________________ (Delayed effective date and/or time) ________________________________________ Signature _________________________________ Type or Print Name & Title Date:_______________________, 20_______ SSL-904 (06/07) (See attached sheet for instructions) American LegalNet, Inc. www.FormsWorkflow.com Application for Certificate of Withdrawal Filing Instructions NAME OF LIMITED LIABILITY COMPANY Use the exact name of the limited liability company or the fictitious name adopted for use if the "real name" was unavailable for use when the limited liability company applied for a certificate of authority to transact business in Kentucky. STATE OF ORGANIZATION Indicate the state or country of organization. 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 effective date may not be later than the 90th day after the date of filing. WHO MAY SIGN If management of the limited liability company is vested in one or more managers, a manager must sign the application. If management is reserved to the members, a member must sign the application. The person executing the document must state his or her title or capacity in which he or she signs. NUMBER OF COPIES Submit the original signed application and two exact or conformed copies. (May be photocopies.) Two file-stamped copies will be returned to the limited liability company as evidence of filing. One file-stamped copy must be filed with the county clerk of the county in which the limited liability company’s registered office was situated. NOTE: Your file-stamped copy shall serve as the Certificate of Withdrawal. FILING FEES The filing fee is $40.00. Your check should be made payable to the "Kentucky State Treasurer". MAILING ADDRESS Trey Grayson Secretary of State P O Box 718 Frankfort, KY 40602-0718 OFFICE LOCATION Room 154, Capitol Building 700 Capital Avenue Frankfort, KY 40601 WEB SITE ADDRESS Our home page address is www.sos.ky.gov Click on “On Line Business Database” for information on status of all business entities in Kentucky. Forms are also available on our web site. For further information, call (502) 564-2848 press 2 and then press 3 or try our web site. NOTE: The limited liability company must be in “good standing” upon the records of the Secretary of State before current statements or documents can be filed (30 KAR 1:010). American LegalNet, Inc. www.FormsWorkflow.com