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Certificate Of Cancellation Of Foreign Limited Liability Company Registration Form - Ohio Secretary Of State

J. Kenneth Blackwell

Prescribed by

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CERTIFICATE OF CANCELLATION OF FOREIGN

LIMITED LIABILITY COMPANY REGISTRATION

The undersigned limited liability company

hereby certifies that it is no longer transacting business

(Registration Number)

in the State of Ohio and hereby makes the following statements for the purpose of surrendering its authority to transact

business in Ohio:

FIRST:

The name of the limited liability company in its state of organization or registration is:

SECOND:

The name under which the limited liability company registered to transact business in Ohio is:

THIRD:

The limited liability company is formed under the laws of the state/country of:

FOURTH:

The limited liability company

the authority of its registered agent to accept service

of process, notices and demands on its behalf.

FIFTH:

The address to which a person may mail a copy of any process, notice, or demand against the company is:

(street address)

(city, township, or village)

(state)

(zip code)

If this mailing address changes in the future, the limited liability company hereby agrees to notify the Ohio Secretary of State

of such change.

(Item “Fourth” MUST be completed IF the limited liability company revokes the

authority of its registered agent to accept service of process, notices and demands on its behalf. If the limited

liability company indicates in item "Fourth” that the authority of its registered agent is NOT revoked, then "Not

Applicable" may be entered in item 'Fourth'")

IN WITNESS WHEREOF, the undersigned duly authorized representative of said limited liability company has executed this

certificate on

(date)

Signature:

Name:

Its: Authorized Representative

[Ohio Revised Code Section 1705.57]

131-LFS

Page 1 of 1

Version: 7/15/99

Certificate Of Cancellation Of Foreign Limited Liability Company Registration Form - Ohio Secretary Of State

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