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. Fee: $70 In compliance with the requirements of the applicable provisions of 15 Pa.C.S. � 8833 (relating to certificate of denial of limited liability company authority), the undersigned person desiring to effect a certificate of denial of limited liability company authority hereby states that: 1. The name of the limited liability company is: __________________________________________________________ 2. The current registered office address as on file with the Department of State. Complete part (a) OR (b) � not both: (a) _______________________________________________________________________________________________ Number and street City State Zip County (b) c/o: ____________________________________________________________________________________________ Name of Commercial Registered Office Provider County 3. The date the Certificate of Authority to which this denial pertains was filed: ______________________________ Date (MM/DD/YYYY) 4. I deny the grant of authority in the Certificate of Authority listed above. IN TESTIMONY WHEREOF, the undersigned has caused this Certificate of Denial of Limited Liability Company Authority to be signed thereof this _______ day of ___________________, 20_______. ______________________________________________________________ Name of Limited Liability Company ______________________________________________________________ Signature ______________________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-8833 � Instructions 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? This form may be used by a person named in a filed Certificate of Authority pertaining to a limited liability company to deny such authority. The Certificate of Denial operates as a restrictive amendment to the Certificate of Company Authority and a certified copy may be recorded by the company or the person that delivered the Certificate of Denial to the Department of State for filing. The Certificate of Denial affects only the authority of a person to bind a company with respect to persons that are not partners. Applicable Law For relations of members and managers to persons dealing with limited liability company, in general, see 15 Pa.C.S. �� 8831-8835. Statutes are available on the Pennsylvania General Assembly website, www.legis.state.pa.us, by following the link for Statutes. 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 limited liability company. The name on this line must match exactly the company name as on file with the Department at the time the Certificate of Denial of Company Authority is submitted for filing. This field is required. 2. Current address. The address provided must be the company's registered office address on file with the Department of State at the time the Certificate of Denial of Company Authority is submitted for filing. 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. This field should give the date the Certificate of Authority to which the denial pertains was filed in the Department of State. This field is required. 4. Mandatory statement. This field is required. Signature and Verification A Certificate of Denial of Company Authority by a person must be signed by that person. 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. American LegalNet, Inc. www.FormsWorkFlow.com