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 Statement of Qualification (Limited Liability Partnership) CSQ __________________________________________________________________________________________ Pursuant to the provisions of KRS 14A and KRS 362, the undersigned applies to cancel a statement of qualification. 1. The name of the limited liability partnership is: _________________________________________________________________________________________. (The name must be identical to the name on record with the Secretary of State) 2. The date the Statement of Qualification was filed with the Office of the Secretary of State_______________________. 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 limited liability partnership cancels its Statement of Qualification. We/I declare under penalty of perjury under the laws of the state of Kentucky that the foregoing is true and correct. ______________________________________ ________________________________ __________________________ Signature of Partner Printed Name Date ______________________________________ ________________________________ __________________________ Signature of Partner Printed Name Date (01/12) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS CANCELLATION OF STATEMENT OF QUALIFICATION NAME Use the exact name of the business entity as registered on file with the Office of the Secretary of State. DATE OF FILING Give the date the statement of qualification was filed with the Secretary of State. 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. 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 a partner or other person authorized to act on behalf of the partnership. 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 $40.00. 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