Non-Refundable Processing Fee: I, , hereby declare and affirm that (Name) I am a(n) (Officer/Director, General Partner, or Member/Manager) of the business entity listed above, which was involuntarily dissolved on , 20 , under provisions of Utah law. (Required) Is this a female owned business? Yes No Is this a minority owned business? Yes No If yes, please specify: American LegalNet, Inc. www.FormsWorkFlow.com