L-123 (4/94) New Jersey Division of Revenue Certification of Resignation of Registered Agent Without Successor (For Use by a Limited Liability Company) To: New Jersey Department of the Treasury, Division of Revenue RE: _______________________________________________________ (Limited Liability Company) 1. In accordance with provisions of NJSA 42, I _____________________________________ at (Agent Name) _______________________________________ ___________________________ _____________ (No. and Street) (City and State) (Zip) the address of the registered office of the above-named Limited Liability Company formed under the laws of _________________________ (State) DO HEREBY DECLARE THAT: I sent a copy of said resignation by certified mail No. _________________________recorded at the Post Office of _________________________ with return receipt requested to _________________________ (City and State) being the last-known manager/member of said LLC known to me, at the address known to me at __________________________________________ ___________________________ ___________ (No. and Street) (City and State) (Zip) Certified mail was ___ accepted by ____________________________ 2. Attached is a copy of my resignation, mailed on ____________________ (Date) __ was not accepted. 3. Service of notice of my resignation has not been made as required because: (Leave blank if not applicable) It is understood that my resignation shall become effective upon 30 days after filing of the certificate with the Treasurer or upon designation by the LLC of a new registered agent, whichever is earlier. ______________________________________ Signature of Resigning Agent 4. ______________ Date NJ Division of Revenue, PO Box 308, Trenton, NJ 08646 American LegalNet, Inc. www.USCourtForms.com Rev 7/18/05 Instructions for Form L-123 CERTIFICATION OF RESIGNATION OF REGISTERED AGENT WITHOUT A SUCCESSOR LIMITED LIABILITY COMPANIES (Title 42:2B) STATUTORY FEE: $25 The MANDATORY fields are: Business Name List the LLC name as it appears on the records of the State Treasurer. Agent Name and Office List the registered agent name and office as they appear on the records of the State Treasurer. State of Formation List the state in which the LLC was formed. Declaration of Mailing Add a statement that indicates that a copy of the resignation was sent via certified mail, return receipt requested. Include the following information: certified mail number; post office from which mailing was done; mailing address (must be to last-known member or manager); and indication of whether the mailing was accepted or not, and if accepted, by whom. If the mailing was not accepted, provide an explanation. Form L-123 provides all of the necessary blanks and statements for these filing requirements. Date That Resignation Was Mailed List the mailing date. ATTESTATIONS Add a statement indicating an understanding that the resignation is effective upon the filing of the change form with the Division of Revenue, or upon the designation of a new agent/office by the affected LLC, whichever is earlier. ATTACHMENTS Attach a copy of the resignation. EXECUTION The resigning agent must sign. Also, list the date of execution (signature). ********** These documents should be filed in duplicate. Non-profits should file in triplicate. Make checks payable to: TREASURER, STATE of NEW JERSEY. (No cash, please) Mail to: Division of Revenue, PO Box 308, Trenton, NJ 08646 American LegalNet, Inc. www.USCourtForms.com