CERTIFICATE OF DISSOLUTION OF A BUSINESS NAME In accordance with § 59.1-69 of the Code of Virginia, 1950, as amended, I/we hereby certify that the business name listed below has previously been recorded in the Chesterfield Circuit Court and has been dissolved as listed below: Business Name: ____________________________________________ Business Address: ____________________________________ ____________________________________ (City State & Zip) I/We hereby certify that this business was dissolved as of this ________ day of ________________________, ________. ____________________________________________ Owner Name (Please Print) _____________________________________________ Owner Signature (Please Sign) ____________________________________________ Owner Name (Please Print) _____________________________________________ Owner Signature (Please Sign) NOTARY PUBLIC / CHESTERFIELD COUNTY CIRCUIT COURT CLERK USE ONLY Commonwealth/State of ___________________________ City/County of______________________________________ Subscribed and sworn to/affirmed before me on this date by the above-named person(s). ______________________ Date _____________________________________________ CLERK DEPUTY CLERK NOTARY PUBLIC My Commission Expires:_________________________ Notary Registration Number: __________________ VIRGINIA: In the Clerk's Office of the Circuit Court of the County of Chesterfield, the _______ day of _________________, ________, this certificate was presented and admitted to record at ____________o'clock _________M. Teste: Mary E. Craze, Clerk By:______________________________________, Deputy Clerk Rev 04/01/2014 American LegalNet, Inc. www.FormsWorkFlow.com