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APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF
CONNIE LAWSON
A FOREIGN LIMITED LIABILITY COMPANY
SECRETARY OF STATE
CORPORATIONS DIVISION
State Form 49461 (R2 / 4-12)
302 W. Washington Street, Room E018
Approved by State Board of Accounts, 1999
Indianapolis, Indiana 46204
Telephone: (317) 232-6576
INSTRUCTIONS:
Use 8 1/2" x 11" white paper for inserts.
Indiana Code 23-18-11-13
Present original and two (2) copies to address in upper right corner of this form.
FILING FEE IS $30.00
Please TYPE or PRINT.
Upon completion of filing the Secretary of State will issue a receipt.
APPLICATION FOR CERTIFICATE OF WITHDRAWAL OF
Name of Limited Liability Company
A FOREIGN LIMITED LIABILITY COMPANY ADMITTED TO TRANSACT BUSINESS IN THE STATE OF INDIANA
The undersigned manager or member of the above, _________________________________________________________ LLC
(hereinafter referred to as the "LLC"), which exists pursuant to the provisions of ____________________________________ as
(state or country)
amended, desiring to effectuate the withdrawal of the LLC from the State of Indiana, certifies the following facts:
ARTICLE I - NAME
Name of LLC
State or country in which it is organized
ARTICLE II - REPRESENTATION BY THE WITHDRAWING LLC
The LLC received its Certificate of Authority from the State of Indiana on _______________________________________ and is
no longer transacting business in Indiana. The LLC surrenders its authority to transact business in Indiana.
ARTICLE III - SERVICE OF PROCESS
The LLC revokes the authority of ________________________________________________________________________, its
Registered Agent to accept service of process on its behalf and appoints the Secretary of State as its agent for service of process
in any proceeding based on a cause of action arising during the time it was authorized to transact business in Indiana. A copy of
any such process served on the Secretary of State should be mailed to the following address of the LLC:
Address of LLC (number and street, city, state, and ZIP code)
The Limited Liability Company shall notify the Secretary of State in the future of any change in its mailing address.
In witness whereof, the undersigned being the ______________________________________________________________ of
(Manager or member)
said LLC executes this Application for Certificate of Withdrawal and verifies, subject to penalties of perjury, that the statements
contained herein are true this ___________ day of ____________________________________ , __________.
Signature
Printed name
1
