Form Llc-10 - Statement Of Dissociation
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FORM LLC-10
WWW.
USINESS
7/2008
Nonrefundable Filing Fee: $25.00
STATE OF HAWAII
*LLC10*
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
Business Registration Division
Clear Info
335 Merchant Street
Mailing Address: P.O. Box 40, Honolulu, Hawaii 96810
Phone No. (808) 586-2727
STATEMENT OF DISSOCIATION
(Section 428-704, Hawaii Revised Statutes)
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK
The undersigned, submitting this Statement, do hereby certify as follows:
1.
The name of the limited liability company is:
_______________________________________________________________________________________________________________
2.
In compliance with Part VII of the Hawaii Uniform Limited Liability Company Act, the name of the member that has been
dissociated from the limited liability company is:
_______________________________________________________________________________________________________________
We certify, under the penalties set forth in the Hawaii Uniform Limited Liability Company Act, that we have read the above
statements, we are authorized to make this change, and that the statements are true and correct.
Signed this ____________day of ___________________________________, __________
_______________________________________________________
_________________________________________________________
(Type/Print Name & Title)
(Type/Print Name & Title)
_______________________________________________________
_________________________________________________________
(Signature)
(Signature)
Instructions: Statement must be typewritten or printed in black ink, and must be legible. The statement must be signed and
certified by the dissociated member or by at least one manager of a manager-managed company or by at least one member of a
member-managed company. All signatures must be in black ink. Submit original statement together with the appropriate fee.
Line 1. State the full name of the limited liability company.
Line 2. State the full name of the dissociated member.
Filing Fees: Filing fee ($25.00) is not refundable. Make checks payable to DEPARTMENT OF COMMERCE AND
CONSUMER AFFAIRS. Dishonored Check Fee $25.00.
For any questions call (808) 586-2727. Neighbor islands may call the following numbers followed by 6-2727 and the # sign:
Kauai 274-3141; Maui 984-2400; Hawaii 974-4000, Lanai & Molokai 1-800-468-4644 (toll free).
Fax: (808) 586-2733
Email Address:
breg@dcca.hawaii.gov
NOTICE: THIS MATERIAL CAN BE MADE AVAILABLE FOR INDIVIDUALS WITH SPECIAL NEEDS. PLEASE CALL THE
DIVISION SECRETARY, BUSINESS REGISTRATION DIVISION, DCCA, AT 586-2744, TO SUBMIT YOUR REQUEST.
ALL BUSINESS REGISTRATION FILINGS ARE OPEN TO PUBLIC INSPECTION. (SECTION 92F-11, HRS)
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