Form Fs 0704 - Statement Of Dissociation
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1MISSISSIPPI SECRETARY OF STATE
POST OFFICE BOX 136
JACKSON, MISSISSIPPI 39205-0136
CUSTOMER SERVICE 601-359-1633
Statement of Dissociation
Filing Fee $25.00. Type or print legibly in blue or black ink. Please do not highlight or write above this line.
1. Name of partnership currently on file:
2. Statement of Partnership Authority date:
Business ID Number:
3. Name as set forth in Statement of Partnership Authority, if different from current name:
4. The following partner is dissociated from the above named partnership:
5. Declaration and Signature:
I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF MISSISSIPPI
THAT THE FOREGOING IS TRUE AND CORRECT OF MY OWN KNOWLEDGE.
____________________________________________
_______________________________________
Partner Signature
Partner (if necessary)
Date:____________
Date:_______________
________________________________________
__________________________________
Print Name
Print Name
IMPORTANT: Failure to include any of the above information and submit the filing fee may cause this filing to
be rejected.
Submit completed form along with the filing fee of $25.00 to Mississippi Secretary of State, Business Services
Division, Post Office Box 136, Jackson, Mississippi 39205-0136.
Effective Date: January 1, 2007
SOS PARTNERSHIP FORM FS 0704
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