PENNSYLVANIA DEPARTMENT OF STATE CORPORATION BUREAU Certificate of Cancellation of Registration-Foreign (15 Pa.C.S. § 8586) Limited Partnership Registered Limited Liability Partnership Registered Limited Liability Company Document will be returned to the name and address you enter to the left. Name Address City ⇐ State Zip Code Fee: $70 In compliance with the requirements of 15 Pa.C.S. § 8586 (relating to cancellation of registration), the undersigned association, desiring to withdrawal from doing business in this Commonwealth, hereby states that: 1. The name under which the association was registered (or last registered) to do business in the Commonwealth of Pennsylvania is: 2. The (a) address of its initial registered office in this Commonwealth or (b) name of its commercial registered office provider and the county of venue is: (a) Number and street City State Zip (b) Name of Commercial Registered Office Provider c/o: County County 3. The name of the jurisdiction under the laws of which the association was organized: 4. The date on which the association registered to do business in this Commonwealth: 5. The association herewith withdraws from doing business in this Commonwealth. American LegalNet, Inc. www.FormsWorkflow.com DSCB:15-8586-2 6. Notice of its intention to withdraw from doing business in this Commonwealth was mailed by certified or registered mail to each municipal corporation in which the registered office or principal place of business of the association in this Commonwealth is located. 7. Process in any action upon any liability incurred before the filing hereof may be sent to the following: Number and street City State Zip County IN TESTIMONY WHEREOF, the undersigned association has caused this Certificate of Cancellation of Registration to be signed by a duly authorized general partner, member or manager thereof this day of , . Name of Association Signature Title American LegalNet, Inc. www.FormsWorkflow.com DSCB: 15-8586 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. 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. C. The following, in addition to the filing fee, shall accompany this form: (1) Tax clearance certificates from the Department of Revenue and from the Bureau of Employment Security of the Department of Labor and Industry evidencing payment of all taxes and charges payable to the Commonwealth. (2) Any necessary governmental approvals. D. It is not necessary to submit to the Department the original or an amended certificate of registration for cancellation. E. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkflow.com