Page 1 of 4Form 567Last Revised: 06/2019 Toll Free: 877.767.3453 | Central Ohio: 614.466.3910 OhioSoS.gov | business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Filing Form Cover LetterPlease return the approval certificate to: Address: City: ZIP Code: Phone Number: E-mail Address: Check here if you would like to receive important notices via e-mail from the Ohio Secretary of State's office regarding Business Services. Check here if you would like to be signed up for our Filing Notification System for the business entity being created or updated by filing this form. This is a free service provided to notify you via e-mail when any document is filed on your business record. Please make checks or money orders payable to: "Ohio Secretary of State" Type of Service Being Requested: (PLEASE CHECK ONE BOX BELOW) Regular Service: Only the filing fee listed on page one of the form is required and the filing will be processed in approximately 3-7 business days. The processing time may vary based on the volume of filings received by our office. Expedite Service 1: By including an Expedite fee of $100.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 2 business days after it is received by our office. Expedite Service 2: By including an Expedite fee of $200.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 1 business day after it is received by our office. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Expedite Service 3: By including an Expedite fee of $300.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 4 hours after it is received by our office, if received by 1:00 p.m. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Preclearance Filing: A filing form, to be submitted at a later date for processing, may be submitted to be examined for the purpose of advising as to the acceptability of the proposed filing for a fee of $50.00. The Preclearance will be complete within 1-2 business days. Name (Individual or Business Name): To the Attention of (if necessary): State American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4Form 567Last Revised: 06/2019Toll Free: 877.767.3453 Central Ohio: 614.466.3910 OhioSoS.gov business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Mail this form to one of the following: Regular Filing (non expedite) P.O. Box 1329 Columbus, OH 43216 Expedite Filing (Two business day processing time. Requires an additional $100.00) P.O. Box 1390 Columbus, OH 43216 (4) (2) (3) Statement of Denial / Dissociation / Dissolution (Partnership / Limited Liability Partnership) Filing Fee: $50 (190-PSC) Form Must Be Typed (CHECK ONLY ONE (1) BOX) (1) Statement of Denial of Partnership Authority (PDN) Statement of Denial of Partner Status (PDN) Statement of Dissociation (PDA) Statement of Dissolution (PDS) Name of Partnership Registration Number The person submitting this form denies the authority stated in the Statement of Partnership Authority that was filed on: State specific authority being denied: (Optional) Date (MM/DD/YYYY) The person submitting this form denies that the following person is a partner. The following partner(s) is (are) dissociated from the partnership: Date of Names Dissociation Address (Optional) (Optional) Name Complete if box (1) is checked Complete if box (2) is checked Complete if box (3) is checkedForm 567 Prescribed by: For screen readers, follow instructions located at this path. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4Form 567Last Revised: 06/2019 The partnership has dissolved and is winding up its business. Complete if box (4) is checked Print Name By (if applicable) Signature Print Name By (if applicable) SignatureBy signing and submitting this form to the Ohio Secretary of State, the undersigned hereby certifies that he or she has the requisite authority to execute this document.Required Must be signed by an authorized representative. If authorized representative is an individual, then they must sign in the "signature" box and print their name in the "Print Name" box. If authorized representative is a business entity, not an individual, then please print the business name in the "signature" box, an authorized representative of the business entity must sign in the "By" box and print their name in the "Print Name" box. American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4Form 567Last Revised: 06/2019This form should be used to file a statement of denial, statement of dissociation or a statement of dissolution. Check box one to file a statement of denial of partnership authority, check box two to file a statement of denial of partner status, check box three to file a statement of dissociation and check box four to file a statement of dissolution. Name and Registration Number of the Partnership The name and registration number of the partnership must be provided. Statement of Denial Pursuant to Ohio Revised Code 2471776.34, a partner or a person named as a partner may file a statement of denial. The statement of denial may include denial of a person's authority or status as a partner. A statement of denial is a limitation on authority under divisions (D) and (E) of section 1776.33 of the Revised Code. Statement of Dissociation Pursuant to Ohio Revised Code 2471776.57, a dissociated partner or the partnership may file a statement of dissociation stating that the partner is dissociated from the partnership. Provide the name of the partner or partners in the space provided. Statement of Dissolution Pursuant to Ohio Revised Code 2471776.65, after dissolution, a partner who has not wrongfully dissociated may file a statement of dissolution stating the partnership has dissolved and is winding up its business. Additional Provisions If the information you wish to provide for the record does not fit on the form, please attach additional provisions on a single-sided, 8 1/2 x 11 sheet(s) of paper. Signature(s) After completing all information on the filing form, please make sure that the form is signed by an authorized representative. **Note:240 Our office cannot file or record a document that contains a social security number or tax identification number.240 Please do not enter a social security number or tax identification number, in any format, on this form. Instructions for Statement of Denial/Dissociation/Dissolution American LegalNet, Inc. www.FormsWorkFlow.com