LB-0288 (REV 6/17) RDA 10183 Tennessee Bureau of Workers325 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM 1-7 NOTICE OF CORPORATE OFFICER325S REVOCATION OF EXEMPTION The original form is to be filed with the Corporation with a photocopy kept by the corporate officer filing the form. This form is not to be filed with the Bureau of Workers325 Compensation. It can be filed only if a corporate officer elects to revoke a previously-filed Form I-6. I, , being a Corporate Officer employed Printed Name and Title by elect to withdraw my previously filed Form I-6 and no longer wish to be exempt from the Tennessee Workers325 Compensation Act. Signature Date Social Security Number Business Mailing Address Business Street Address (if different from above) City State ZIP American LegalNet, Inc. www.FormsWorkFlow.com