Form Cwa - Certificate Of Withdrawal Of Assumed Name (Domestic Or Foreign Business Entity)
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1
2C
K
OMMONWEALTH OF
ENTUCKY
E
N. W
, S
S
LAINE
ALKER
ECRETARY OF
TATE
_________________________________________________________________________________________________________________________
Division of
Business Filings
Certificate of Withdrawal of Assumed Name
CWA
Business Filings
(Domestic or Foreign Business Entity)
PO Box 718
Frankfort, KY 40602
(502) 564-3490
______________________________________________________________________________________
Pursuant to the provisions of KRS 365, the undersigned applicant applies to withdraw an assumed name and, for that
purpose, submits the following statements:
1. The assumed name to be withdrawn is ______________________________________________________________.
(The name must be identical to the name on record with the Secretary of State.)
2. The assumed name has been discontinued by_________________________________________________________.
(Must be the exact name of the entity or partners)
3. 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)
4. The date the original certificate as filed: ______________________________________________________________.
5. The “real name” is
):
(you must check one
_____a Domestic General Partnership
_____a Foreign General Partnership
_____a Domestic Limited Liability Partnership
_____a Foreign Limited Liability Partnership
_____a Domestic Limited Partnership
_____a Foreign Limited Partnership
_____a Domestic Business Trust
_____a Foreign Business Trust
_____a Domestic Corporation
_____a Foreign Corporation
_____a Domestic Limited Liability Company
_____a Foreign Limited Liability Company
6. The mailing address is:
____________________________________________ __________________________ ___________________ ______
Street Address or Post Office Box Numbers
City
State
Zip
I declare under penalty of perjury under the laws of Kentucky that the forgoing is true and correct.
_________________________________________ ________________________ _________________ ______
Signature of Authorized Party
Printed Name
Title
Date
(04/11)
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