STATE OF SOUTH CAROLINA SECRETARY OF STATE MEMBERS STATEMENT OF DISSOCIATION FROM A LIMITED LIABILITY COMPANY TYPE OR PRINT CLEARLY IN BLACK INK The following member of the Limited Liability Company hereby files this statement of Dissociation in accordance with Section 33-44-704 of the 1976 South Carolina Code of Laws, as amended. 1. Name of the Limited Liability Company from which a member has dissociated: ________________________________________________________________________________ 2. Name of member who has dissociated from the Limited Liability Company: ________________________________________________________________________________ ________________________________________________________________________________ Street Address tate ________________________________________________________________________________ City S Zip Code 3. Unless otherwise specified, this statement is effective when endorsed for filing by the Secretary of State. Specify any delayed effective date and time: ________________________________________________________________________________ 4. This statement is being filed by: [] a. The dissociating member: ________________________________________ Signature of member Date [] b. The Limited Liability Company: ________________________________________ Signature Date ________________________________________ Name Capacity American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS 1. 2. 3. File two copies of this form, the original and either a duplicate original or a conformed copy. If space in this form is insufficient, please attach additional sheets containing a reference to the appropriate paragraph in this form, or prepare this using a computer disk, which will allow for expansion of space on this form. This form must be accompanied by the filing fee of $2.00 payable to the Secretary of State. Return to: Secretary of State 1205 Pendleton Street, Suite 525 Columbia, SC 29201 Form Revised by South Carolina Secretary of State, May 2011 American LegalNet, Inc. www.FormsWorkFlow.com