Form Mllp-13a - Amended Annual Report (2012) Page 2

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DATED __________________________
Partner(s)*
___________________________________________________
___________________________________________________
(signature)
(type or print name and capacity)
For Partner(s) which are 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 Maine Secretary of State.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
TEL. (207) 624-7740
Form No. MLLP-13A (2 of 2) 10/25/2012

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