AFFIDAVIT OF FACTS PERTAINING TO ASSUMED NAME CERTIFICATE WITHDRAWAL This form is used in withdrawing individual names from business (es) not for withdrawing entire business (es) COUNTY CLERK, FORT BEND COUNTY 301 JACKSON, RICHMOND, TEXAS 77469-3108 | 281-341-8685 STATE OF TEXAS COUNTY OF FORT BEND THIS IS TO CERTIFY THAT I, __________________________________________________________________________________ , PRINTED NAME LAURA RICHARD OF ________________________________ COUNTY, STATE OF _______________________, HAVE BEEN CONNECTED WITH THE COUNTY OF RESIDENCE STATE OF RESIDENCE BUSINESS OF ____________________________________________________________________________ AS EVIDENCE BY THE BUSINESS NAME ATTACHED CERTIFICATE AS FILED IN THE OFFICE OF COUNTY CLERK, FORT BEND COUNTY, AND THAT I AM NO LONGER ASSOCIATED WITH SAID BUSINESS AS OF THIS ___________ DAY OF ______________________________, _________. ________________________________________________________ SIGNATURE OF PERSON WITHDRAWING ________________________________________________________ PRINTED NAME OF PERSON WITHDRAWING ****************************************************************************** STATE OF TEXAS COUNTY OF FORT BEND } } Before me, the undersigned authority, on this day personally appeared ______________________________________________ known (or proven) to me to be the person whose name is subscribed in the above statement and acknowledged to me that they executed the same for the purpose and consideration therein expressed. GIVEN UNDER MY HAND AND SEAL OF OFFICE, THIS ___________ DAY OF ______________________________, ___________. ________________________________________________ SIGNATURE OF NOTARY PUBLIC/DEPUTY COUNTY CLERK PRINTED NAME OF NOTARY PUBLIC/DEPUTY COUNTY CLERK ________________________________________________ REVISED 01/01/2015 American LegalNet, Inc. www.FormsWorkFlow.com