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 Statement of Dissociation (Domestic or Foreign Partnership) SDS __________________________________________________________________________________________ Pursuant to KRS 14A and KRS 362.1, the undersigned applies to qualify and for that purpose submits the following statements: 1. Name of the partnership___________________________________________________________________________ (Name must be identical to the name of record with the Secretary of State) 2. List the partner/partners that is/are dissociated from the partnership. _________________________________________________________________________________________________ _________________________________________________________________________________________________ 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) I/We declare under penalty of perjury under the laws of the state of Kentucky that the foregoing is true and correct. _________________________________________________________________________________________________ Signature of partner or authorized person Type or Print Name Date (01/12) American LegalNet, Inc. www.FormsWorkFlow.com Filing Instructions Statement of Denial of Partnership Authority NAME State the exact name of the partnership as registered with the Office of the Secretary of State. DATE List the date the statement of partnership authority was filed 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 submitted. 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 the general partner or other person authorized by KRS 362. NUMBER OF COPIES If filing via mail or in person, one exact or conformed 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. 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. FILING FEE The filing fee is $20.00. Checks should be made payable to the "Kentucky State Treasurer." MAILING ADDRESS Alison Lundergan Grimes 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 or need additional forms, please feel free to visit our website at www.sos.ky.gov or call (502) 564-3490. (04/11) American LegalNet, Inc. www.FormsWorkFlow.com