C
K
OMMONWEALTH OF
ENTUCKY
T
G
, S
S
REY
RAYSON
ECRETARY OF
TATE
_________________________________________________________________________________________________________________________
Division of Corporations
Certificate of Withdrawal
FLW
Business Filings
(Foreign Limited Liability Company)
PO Box 718
Frankfort, KY 40602
(502) 564-3490
Pursuant to the provisions of KRS Chapter 275, the undersigned hereby applies for a certificate of withdrawal on behalf of
the limited liability company named below and, for that purpose, submits the following statements:
1. The name of the limited liability company is
________________________________________________________________________________________________.
(The name must be identical to the name on record with the Secretary of State.)
2. The state or country of organization is ________________________________________________________________.
3. The limited liability company is not transacting business in Kentucky.
4. The limited liability company hereby surrenders its authority to transact business in Kentucky.
5. The limited liability company hereby revokes the authority of its registered agent in Kentucky to accept service of
process on its behalf and hereby appoints the Secretary of State as its agent for service of process in any proceeding
based upon any cause of action arising during the time it was authorized to transact business in Kentucky.
6. The mailing address to which the Office of the Secretary of State may mail a copy of any process served on the
Secretary of State is:
________________________________________________________________________________________________.
Street Address (No Post Office Box Numbers)
City
State
Zip Code
7. The limited liability company hereby commits to notify the Office of the Secretary of State in the future of any change in
the mailing address in statement 6 above.
8. This application will be effective upon filing, unless a delayed effective date and/or time is provided. The effective date
or the delayed effective date cannot be prior to the date the application is filed. The date and/or time is ______________.
(Delayed effective date
and/or time)
I declare under penalty of perjury under the laws of the state of Kentucky that the foregoing is true and correct.
_________________________________________________________________________________________________
Signature of Member, Manager or Authorized Party
Printed Name & Title
Date
(09/09)