Filing Fee $20.00
FOREIGN
LIMITED LIABILITY COMPANY
STATE OF MAINE
STATEMENT OF INTENTION TO
DO BUSINESS UNDER AN
Deputy Secretary of State
ASSUMED NAME ONLY
A True Copy When Attested By Signature
______________________________________
Deputy Secretary of State
(Name of Limited Liability Company in Jurisdiction of Organization)
Pursuant to 31 MRSA §603.2.B., the undersigned limited liability company executes and delivers for filing this statement of intent:
FIRST:
The address of the registered office of the limited liability company in the State of Maine is _____________________
_________________________________________________________________________________________________
(street, city, state and zip code)
SECOND:
The limited liability company shall not do business in the State of Maine under its true name as it appears above and
on the record in the jurisdiction of organization, but shall instead do business in this State under the assumed name of
_________________________________________________________________________________________________
AUTHORIZED SIGNATURE(S)*
DATED __________________________
___________________________________________________
____________________________________________________
(signature)
(type or print name and capacity)
For Authorized Signature(s) on behalf of Entities
Name of Entity __________________________________________________________________________________________________
By ________________________________________________
____________________________________________________
(authorized signature)
(type or print name and capacity)
*Certificate MUST be signed by at least one duly authorized person.
The execution of this certificate constitutes an oath or affirmation under the penalties of false swearing under Title 17-A, section 453.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MLLC-12F
Rev. 4/16/2001
TEL. (207) 624-7740