PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Return document by email to: _________________________________ Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/. Fee: $70 Check one: From General Partnership (§ 8474) From Limited Partnership (§ 8665) In compliance with the requirements of 15 Pa.C.S. § 8474 or 8665 (relating to certificate of dissociation), the undersigned person dissociated as a partner, hereby states that: 1. The name of the general or limited partnership is: ___________________________________________________ 2. Complete part (a) OR (b) ­ not both: (a) The partnership is a domestic general partnership or limited liability partnership and the address, including number and street, if any, of its principal place of business is: ____________________________________________________________________________________________________ Number and street of principal office City State Zip County (b) The partnership is a domestic limited partnership or limited liability limited partnership, and the (1) address of its current registered office in this Commonwealth or (2) name of its commercial registered office provider and the county of venue is: (Complete (1) or (2), not both) (1) _________________________________________________________________________________________________ Number and Street City State Zip County (2) _________________________________________________________________________________________________ Name of Commercial Registered Office Provider County 3. The name of the person who has dissociated from the partnership: _____________________________________ 4. Check one. The person named in field 3 has: Dissociated from the general partnership. Dissociated as a general partner from the limited partnership. IN TESTIMONY WHEREOF, the undersigned person has caused this Certificate of Dissociation to be executed this ___________ day of ___________________________, 20 . ___________________________________________________________ Name of Person ___________________________________________________________ Signature ___________________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-8474/8665­Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Website: www.dos.pa.gov/corps General Information Typewritten is preferred. If handwritten, the form must be legible and completed in black or blue-black ink in order to permit reproduction. The nonrefundable filing fee for this form is $70. Checks should be made payable to the Department of State. Checks must contain a commercially pre-printed name and address. This form and all accompanying documents, including any necessary governmental approvals, shall be mailed to the address stated above. Who should file this form? When a person has dissociated or withdrawn as a general partner from a general or limited partnership, that person may deliver to the Department of State a Certificate of Dissociation. Applicable Law For requirements for Certificate of Dissociation, see 15 Pa.C.S. § 8474 (general partnerships) and 15 Pa.C.S. § 8665 (limited partnerships). For events which cause dissociation, see 15 Pa.C.S. § 8461 (general partnerships) and 15 Pa.C.S. § 8663 (limited partnerships). Statutes are available on the Pennsylvania General Assembly website, www.legis.state.pa.us, by following the link for Statutes. partnership. This field is required. Post office boxes are not acceptable for any address. Under 15 Pa.C.S. § 135(c) (relating to addresses) an actual street or rural route box number must be used as an address, and the Department of State is required to refuse to receive or file any document that sets forth only a post office box address. 3. Set forth the name of the person who has dissociated from the partnership. This field is required. 4. Check appropriate box for either general or limited partnership. Check only one box. Mandatory statement. This field is required. Signature and Verification A Certificate of Dissociation must be signed by the person dissociated as a general partner. Signing a document delivered to the Department for filing is an affirmation under the penalties provided in 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) that the facts stated in the document are true in all material respects. This field is required. Form Instructions Enter the name and mailing address to which any correspondence regarding this filing should be sent. This field must be completed for the Bureau to return the filing. If the filing is to be returned by email, an email address must be provided. An email will be sent to address provided, containing a link and instructions on how a copy of the filed document or correspondence may be downloaded. Any email or mailing addresses provided on this form will become part of the filed document and therefore public record. 1. Give the exact name of the general or limited partnership. The name on this line must match exactly the association name as shown in Department's records, if applicable, at the time the Certificate of Dissociation is submitted for filing. This field is required. 2. Current address. The address provided must be the address of the partnership's principal place of business if the partnership is a domestic general partnership or limited liability partnership (a) or the partnership's registered office address (b) as on file with the Department of State at the time the Certificate of Dissociation is submitted for filing, if the partnership is a limited partnership or limited liability limited American LegalNet, Inc. www.FormsWorkFlow.com