PENNSYLVANIA DEPARTMENT OF STATE CORPORATION BUREAU Statement of Withdrawal from Registered Limited Liability Partnership (15 Pa.C.S. § 8205) Name Document will be returned to the name and address you enter to the left. Address ⇐ City State Zip Code Fee: $70 In compliance with the requirements of 15 Pa.C.S. § 8205(c) (relating to statement of withdrawal), the undersigned partner of a registered limited liability partnership, desiring to evidence the partner's withdrawal from a registered limited liability partnership, hereby certifies that: 1. The name is of the registered limited liability partnership is: 2. The name of the person withdrawing is: IN TESTIMONY WHEREOF, the undersigned person has caused this Statement of Withdrawal to be executed this day of , . Name of Person Signature Title American LegalNet, Inc. www.FormsWorkflow.com Department of State Corporation Bureau P. O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Web site: www.dos.state.pa.us/corps Instructions for Completion of Form: A. Typewritten is preferred. If not, the form shall be completed in black or blue-black ink in order to permit reproduction. The filing fee for this form is $70 made payable to the Department of State. B. This form shall be executed by the person identified in the form as withdrawing as a partner from the partnership. If this form is executed by the personal representative of the withdrawing partner, the execution portion of the form should be modified accordingly. C. Under 15 Pa.C.S. § 8205(d) the person withdrawing shall send a copy of the filed statement of withdrawal to the registered limited liability partnership. D. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkflow.com