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STATE OF MONTANA

Prepare, sign, and submit with the proper filing fee.

This is the minimum information required

(This space for use by the Secretary of State only)

CERTIFICATE of WITHDRAWAL

of FOREIGN LIMITED LIABILITY COMPANY

APPLICATION

LINDA McCULLOCH

MAIL:

Secretary of State

P.O. Box 202801

Helena, MT 59620-2801

PHONE:

(406) 444-3665

FAX:

(406) 444-3976

WEB SITE:

sos.mt.gov

Required Filing Fee: $15.00

 24 Hour Priority Handling check box & Add $20.00

 1 Hour Expedite Handling check box & Add $100.00

For the purpose of withdrawing from the State of Montana as a limited liability company

(35-8-1010,

MCA), the undersigned

submits the following statements of fact to the Secretary of State and has attached a certificate by the Department of Revenue to

the effect that the Department of Revenue is satisfied from the available evidence that all taxes imposed by

Title 15,

MCA, have

been paid:

1. The name of the limited liability company is:__________________________________________________________________

2. It is organized under the laws of: ___________________________________________________________________________

3. It is not transacting business or conducting affairs in Montana and it hereby surrenders its authority to transact business in

Montana.

4. It revokes the authority of its registered agent in Montana to accept service 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 this state.

5. Provide a business mailing address to which the secretary of state may mail a copy of any process served on the secretary of

state:

______________________________________________________________________________________________________

Street Address

______________________________________________

_________________________

___________________________

City or town

State

Zip code

6. It will notify the secretary of state in the future of any change in its business mailing address.

7. Optional: “The reason for filing this withdrawal is:______________________________________________________________

_______________________________________________________________________________________________________

8. The execution of any document required to be filed with the Secretary of State constitutes an affirmation, under

penalties of false swearing, by each person executing the document that the facts stated therein are true.

(35-1-428,

MCA)

_________________________________________________________________

___________________________________

Signature of Manager/Member

Date

Daytime Contact: Phone _____________________________ Email _________________________________________________

sos.mt.gov/Business/Forms

29-Certificate_of_withdrawal_of_Foreign_Limited_Liability_Company.doc

Revised: 10/01/2013

Certificate Of Withdrawal Of Foreign Limited Liability Company Application Form - State Of Montana - 2013

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