This Box For Office Use Only Page 1 of 2 Limited Liability Company See attached detailed instructions □ No Fee for Standard Service □ Expedited Service $20.00 UBI Number: CERTIFICATE OF CANCELLATION (Foreign) Chapter 25.15 RCW SECTION 1 NAME OF LIMITED LIABILITY COMPANY: (as currently recorded with the Office of the Secretary of State) SECTION 2 ORIGINAL DATE FOR CERTIFICATE OF REGISTRATION: SECTION 3 EFFECTIVE DATE OF CANCELLATION: (please check one of the following) □ □ Upon filing by the Secretary of State Specific Date: __________________ (Specified effective date must be within 90 days AFTER the Cancellation has been filed by the Office of the Secretary of State) SECTION 4 ADDRESS WHERE SERVICE OF PROCESS MAY BE FORWARDED: (REQUIRED) Address: _______________________________City___________________State _Zip Code_______ SECTION 5 REASON FOR CANCELLATION: (if necessary, attach additional information) SECTION 6 MEMBER OR MANAGER SIGNATURE (see instructions page) This document is hereby executed under penalties of perjury, and is, to the best of my knowledge, true and correct. X_______________________________________________________________________________________ Signature Printed Name/Title Date Phone FOREIGN LLC - Cancellation Washington Secretary of State Revised 05/10 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS – CERTIFICATE OF CANCELLATION Please complete all sections of the Certificate of Cancellation. USE DARK INK ONLY. For an electronic, fillable version of this form, please visit our website at www.sos.wa.gov/corps Section 1 Provide the Foreign Limited Liability Company (LLC) name as it is currently is recorded with the Office of the Secretary of State. Section 2 List the original filing date of the Foreign Limited Liability Company’s Registration as recorded with the Office of the Secretary of State. Section 3 Choose either upon filing by the Secretary of State or you may indicate an effective date. The effective date can be up to 90 days AFTER filing the cancellation of the Registration by the Office of the Secretary of State. Section 4 A Foreign LLC must complete this section with an address where service of process may be forwarded. Section 6 List the reason(s) for cancellation of the Foreign Limited Liability Company. (if necessary, attach additional information) Section 7 The Certificate of Cancellation must be signed by a member or manager of the LLC or their authorized representative. If signed by an authorized representative you must provide the title and capacity of person signing and whom they represent. Additional Information: UBI Number: Please enter your existing Unified Business Identifier (UBI Number) as currently recorded with the Office of the Secretary of State, in the box in the upper right hand corner of page 1. FEES: There is no filing fee for standard service. If expedited service is requested, include an additional $50.00 and write “EXPEDITE” on the outside of the envelope. Make the checks or money orders payable to “Secretary of State”. (All filing fees are non-refundable) Mail completed forms and payment to: Secretary of State Corporation Division 801 Capitol Way S PO Box 40234 Olympia WA 98504-0234 If you have questions, need assistance, or would like to provide feedback please visit the Corporations Division website at www.sos.wa.gov/corps or call 360-725-0377. Print Form FOREIGN LLC - Cancellation Washington Secretary of State Revised 05/10 American LegalNet, Inc. www.FormsWorkFlow.com