Form Mllp-12b - Cancellation Of Authority To Do Business Page 2
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1
2DATED __________________________
Authorized Signature(s)*
___________________________________________________
___________________________________________________
)
(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
(1) at least one partner OR
(2) any duly authorized person.
The execution of this certificate constitutes an oath or affirmation under the penalties of false swearing under
17-A MRSA
§453.
Please remit your payment made payable to the Secretary of State.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MLLP-12B (2 of 2) Rev. 8/1/2004
TEL. (207) 624-7752
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