Page 1of 2DOS-1379-f (Rev. 03/17) New York StateDepartment of State DIVISION OF CORPORATIONS, STATE RECORDS AND UNIFORM COMMERCIAL CODE One Commerce Plaza 99 Washington Ave. Albany, NY 12231-0001 www.dos.ny.govCERTIFICATE OF SURRENDER OF AUTHORITY OF (Insert Name of Foreign Limited Liability Company) Under Section 806 of the Limited Liability Company Law FIRST: The name of the foreign limited liability company as it appears on the index of names in the Department of State is: . If applicable: the fictitious name the foreign limited liability company has agreed to use in New York State is: . SECOND: The jurisdiction of organization of the foreign limited liability company is: . THIRD: The date on which its application for authority to do business in this state was filed with the Department of State is: . FOURTH: The foreign limited liability company surrenders its authority to do business in New York State. FIFTH: The foreign limited liability company hereby revokes the authority of its registered agent, if any, previously designated and it hereby consents that process against it in any action or special proceeding based upon any liability or obligation incurred by it within this state before the filing of the certificate of surrender of authority may be served on the Secretary of State in the manner set forth in Article 3 of the Limited Liability Company Law. SIXTH: The address within or without this state to which the Secretary of State shall mail a copy of any process against the foreign limited liability company served upon him or her is: . X (Signature) (Type or Print Name of Signer) Capacity of signer (Check appropriate box): Member Manager Authorized Person American LegalNet, Inc. www.FormsWorkFlow.com Page 2of 2DOS-1379-f (Rev. 03/17) CERTIFICATE OF SURRENDER OF AUTHORITY OF (Insert Name of Foreign Limited Liability Company) Under Section 806 of the Limited Liability Company Law Filer222s Name and Mailing Address: Name: Company, if Applicable: Mailing Address: City, State and Zip Code: NOTES: 1. The name of the foreign limited liability company and the date of filing of the application for authority must exactly match the records of the Department of State. This information should be verified on the Department of State222s website at www.dos.ny.gov. 2. This form was prepared by the New York State Department of State for filing a certificate of surrender of authority for a foreign limited liability company. It does not contain all optional provisions under the law. You are not required to use this form. You may draft your own form or use forms available at legal supply stores. 3. The Department of State recommends that legal documents be prepared under the guidance of an attorney. 4. The certificate must be submitted with a $60 filing fee made payable to the Department of State. (For office use only) American LegalNet, Inc. www.FormsWorkFlow.com