Form Mllc-10 - Limited Liability Company Statement Of Merger Page 3
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3Must Be Completed By the Fourth Constituent Organization to the Merger
____________________________________________________________________________
_____________________________
(Name and form of participating constituent organization)
(Date)
___________________________________________________
___________________________________________
(*Authorized signature)
(Type or print name and capacity)
___________________________________________________
___________________________________________
(*Authorized signature)
(Type or print name and capacity)
(Copy this page, and modify participant number, if more signature spaces are needed.)
*Pursuant to 31 MRSA
§§1643.1
and 1676.1, this statement of merger must be signed by a person authorized by each constituent
organization that is party to this merger.
The execution of this certificate constitutes an oath or affirmation, under the penalties of false swearing
under17-A MRSA
§453.
Please remit your payment made payable to the Maine Secretary of State.
Submit completed form to:
Secretary of State
Division of Corporations, UCC and Commissions
101 State House Station
Augusta, ME 04333-0101
Telephone Inquiries: (207) 624-7752
Email Inquiries:
CEC.Corporations@Maine.gov
Form No. MLLC-10 (3 of 3) 7/1/2011
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