Withdrawal of Assumed Business Name Certificate 10.03.17 WITHDRAWAL OF ASSUMED NAME CERTIFICATE (NCGS 66 - 71.8 ) Please print legibly. 1. The assumed business name being withdrawn is: 2. The real name of the person or entity engaging in business under the assumed business name is: 3. The current address of the real person named in #2 is: 4. The boo k and page number of the initia l filing that is being withdrawn is: Book , Page . 5. The identification number assigned to the assumed business name by the Secretary of State (SOS ID) is: (Go to www.sosnc.gov/abn/search to look up this number .) 6. The business operating under the assumed name shown in #1 has ceased to engage in business under the assumed business name . 7. The effective date of the withdraw al is: upon filing OR (Please choose one.) ( Date m ust be LATER than the date of filing.) This certificate is signed by the owner/legal representa tive of the person named above, this day of , 20. Signature: Printed/Typed Name: Title: ( See instructio ns for who must sign for various types of business entities.) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Withdrawal of ABN 10.03.17 Instructions for Withdrawal of an Assumed Business Name Certificate You must file a withdrawal in the SAME COUNTY as the initial filing. Item 1: Enter the assumed busin ess name to which this withdrawal applies, as stated on the initial or most recently amended assumed business name certificate. Item 2: Enter a real name of the person or entity engaging in business under the assumed business name as stated on the initial or most rec ently amended assumed business name certificate. Item 3: Enter the current address of the person named in Item 2. Item 4: Enter the book and page number of the initial filing to which the amendment applies. The book and page will be s tamped at the top of the initia l certificate returned to you after recording. Item 5: Enter the SOS ID number that was assigned by the Secretary of State. You can search for your initial certificate containing your SOS ID number www.sosnc.gov /abn/search . Item 6: This is a required statement . No additional information needed. Item 7 : Choose the date that the withdrawal is to be effective. You may make the effective date the date that the withdrawal certificate is filed OR an effective date in the future (effective dates may not be retroactive). Execution of Certificate: Enter the date that you signed the certificate. Cert ificates must be signed by a person with the capacity listed below on behalf of the person(s) named in Item 2: S ole proprietor ship: General Partnership : must be signed by a general pa rtner. Limited partnership : must be signed by a general partner. Corporation : must be signed by an officer of the corporation. Limited Liability Company : must be signed by a manager, director or officer of the LLC. Trust : must be signed by a trustee or oth er person authorized to act on behalf of the trust. In the case of any other legal entity, the certificate must be signed in the name of the entity by an individual authorized to act for the entity. Please note that k nowingly signing a certificate that is false in any material respect is a Class 1 misdemeanor. (See NCGS 247 66 - 71.14) American LegalNet, Inc. www.FormsWorkFlow.com