C
K
OMMONWEALTH OF
ENTUCKY
T
G
, S
S
REY
RAYSON
ECRETARY OF
TATE
_________________________________________________________________________________________________________________________
Division of Corporations
Certificate of Withdrawal
WBT
Business Filings
(Foreign Business Trust)
PO Box 718
Frankfort, KY 40602
(502) 564-3490
_________________________________________________________________________________________________
Pursuant to the provisions of KRS Chapter 386 the undersigned applies for a certificate of withdrawal on behalf of the
business trust named below and, for that purpose, submits the following statements:
1. The name of the business trust 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 date the business trust was authorized to do business in Kentucky is ___________________________________.
4. The Secretary of State may forward to the business trust at the following street address any process served
on the Secretary of State
_________________________________________________________________________________________________
Street Address (No Post Office Box Numbers)
City
State
Zip Code
5. The business trust surrenders its authority to transact business in the Commonwealth.
6. The business trust revokes the authority of its registered agent to accept service of process 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 the Commonwealth. The business trust shall notify the Secretary of State in
the future of any change in its mailing address.
I declare under penalty of perjury under the laws of Kentucky that the forgoing is true and correct.
_________________________________________________________________________________________________
Signature of Trustee
Printed Name
Date
(09/09)