COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION UPA-115 (01/06) STATEMENT OF DISSOCIATION FROM A PARTNERSHIP The undersigned present(s) this statement of dissociation for filing pursuant to § 50-73.115 of the Code of Virginia. 1a. The name of the partnership is ________________________________________________________________________. 1b. The partnership is formed under the laws of ____________________________________. (state or country) 2. The partnership’s SCC ID number is __________________________________________. 3. The following partner, who is named as a partner in a filed statement of partnership authority or in a list maintained by an agent pursuant to § 50-73.93 B of the Code of Virginia, is dissociated from the partnership: ________________________________________________________________________ The individual(s) executing this document personally declare(s) under penalty of perjury that the contents are accurate. 4a. If submitted on behalf of the partnership, the signature of at least two partners: ___________________________ (signature) __________________________ ____________ (printed name) ___________________________ (signature) __________________________ (date) ____________ (printed name) (date) OR 4b. If submitted by a dissociating partner, the signature of the dissociating partner: ___________________________ (signature) __________________________ ____________ (printed name) (date) Telephone number (optional): ___________________________ SEE INSTRUCTIONS ON THE REVERSE American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS Section 50-73.83 of the Code of Virginia requires that this statement be in the English language, typewritten or printed in black, legible and reproducible. The document must be presented on uniformly white, opaque paper, free of visible watermarks and background logos. You can download this form from our website at www.scc.virginia.gov/division/clk/fee_bus.htm. A statement of dissociation for a partnership may be filed if the partnership has filed with the State Corporation Commission a statement of partnership authority that has not been canceled. A partner has the power to dissociate at any time, rightfully or wrongfully, by express will pursuant to subdivision 1 of § 50-73.109 of the Code of Virginia. A statement of dissociation is a limitation on the authority of a dissociated partner for the purposes of subsections D and E of § 50-73.93 of the Code of Virginia. For the purposes of subdivision A3 of § 50-73.113 and subdivision B3 of § 50.73.114 of the Code of Virginia, a person, not a partner is deemed to have notice of the dissociation 90 days after the statement of dissociation is filed. The person who files this statement must promptly send a copy of the statement to every nonfiling partner and to any other person named as a partner in the statement. See § 50-73.83 E of the Code of Virginia. If this statement is submitted by the partnership, it must be signed by at least two partners. If this statement is submitted by a dissociating partner, it must be signed by the dissociating partner. Each person signing this statement must set forth his printed name next to or beneath his signature. A person signing on behalf of a partner that is a business entity should set forth the business entity’s name, his or her printed name, and the capacity in which he or she is signing on behalf of the business entity. See § 50-73.83 C of the Code of Virginia. Submit the original, signed statement to the Clerk of the State Corporation Commission, P.O. Box 1197, Richmond, Virginia 23218-1197, (Street address: 1300 East Main Street, Tyler Building, 1st Floor, Richmond, Virginia 23219), along with a check for the filing fee in the amount of $25.00, payable to the State Corporation Commission. PLEASE DO NOT SEND CASH. If you have any questions, please call (804) 371-9733 or toll-free in Virginia, 1-866-722-2551. American LegalNet, Inc. www.USCourtForms.com