New York State
Department of State
Division of Corporations, State Records
and Uniform Commercial Code
Albany, NY 12231
CERTIFICATE OF SURRENDER OF AUTHORITY
OF
(Insert name of Foreign Limited Liability Company)
Under Section 806 of the Limited Liability Company Law
FIRST:
The name of the limited liability company as it appears on the index of records in the
Department of State is:
(If applicable, the fictitous name the foreign limited liability company has agreed to use in this state
is:
SECOND:
The jurisdiction where the limited liability company was organized is:
THIRD:
The date on which its certificate of authority to do business in this state was filed with the
Department of State is:
FOURTH:
The limited liability company surrenders its authority to do business in New York State.
FIFTH:
The limited liability company hereby revokes the authority of its registered agent, if any,
previously designated and it hereby consents that process against it in any action or special
proceeding based upon any liability or obligation incurred by it within this state before the filing of
the certificate of surrender may be served on the secretary of state in the manner set forth in Article
3 of the Limited Liability Company Law.
SIXTH:
The address within or without this state to which the secretary of state shall mail a copy
of any process against the limited liability company served upon him or her is: __________
X
(Signature)
(Type or print name)
(Title or capacity of signer)
DOS-1379 (01/00)