L-109 (7/03) New Jersey Division of Revenue CERTIFICATE of CANCELLATION Limited Liability Company ( Title NJSA 42 ) This form may be used to cancel a Certificate of Formation of a Limited Liability Company on file with the Division of Revenue. Applicants must insure strict compliance with NJSA 42, the New Jersey Limited Liability Act, and insure that all applicable filing requirements are met. 1. Name of Limited Liability Company: 2. Business Entity Number: 3. Date of formation: 4. State of Formation (foreign entities only) 5. Effective date of cancellation: 6. Reasons for canceling the LLC: The undersigned represent(s) that this filing complies with State law as detailed in NJSA 42 and that they are authorized to sign this form on behalf of the Limited Liability Company. Signature: Name: Date: NJ Division of Revenue, PO Box 308, Trenton NJ 08646 American LegalNet, Inc. www.FormsWorkflow.com (Rev 7/05) Instructions for Form L-109 CERTIFICATE OF CANCELLATION DOMESTIC AND FOREIGN LIMITED LIABILITY COMPANIES (Title 42:2B) STATUTORY FEE: $100 for Domestic; $125 for Foreign LLC The MANDATORY fields are: Field # 1 -- Business Name List the name as it appears on the records of the State Treasurer. Field # 2 � Business Entity Number Provide the 10-digit business entity identification number issued by the State of New Jersey. Field # 3 � Date of Formation List the date the LLC was formed. Field # 4 �State of Formation List the state where the LLC was formed. Required for foreign entities only. Field # 5 � Effective Date Of Cancellation Specify the effective date if it is other than the filing date. The effective date cannot be before the filing date nor can it be more than 30 days after the filing date. The filing date is the date the document is received for processing. Field # 6 -- Reason For Filing Specify the reason for filing the cancellation. ATTESTATIONS Add a statement that indicates that the signers are authorized to sign on behalf of the LLC. Form L-109 provides the statement. EXECUTION (DATE/SIGNATURE) An authorized representative must sign. Also, list the date of execution (signature). **************** These documents should be filed in duplicate. Non-profits should file in triplicate. All annual report obligations should be satisfied prior to submitting the dissolution paperwork. Make checks payable to: TREASURER, STATE OF NEW JERSEY. (No cash, please) Mail to: NJ Division of Revenue, PO Box 308, Trenton, NJ 08646 American LegalNet, Inc. www.FormsWorkflow.com