Natalie E. Tennant
Penney Barker, Manager
Secretary of State
Corporations Division
1900 Kanawha Blvd E.
Tel: (304)558-8000
Bldg 1, Suite 157-K
Fax: (304)558-8381
Charleston, WV 25305
Website:
E-mail:
WEST VIRGINIA
FILE ONE ORIGINAL
STATEMENT OF DISSOCIATION
Office Hrs: Monday - Friday
(Two if you want a filed
8:30 a.m. – 5:00 p.m. ET
stamped copy returned to you)
FOR A LIMITED LIABILITY COMPANY
FEE: $15.00
**** In accordance with WV Code §31B-7-704, the undersigned organization adopts the following ****
Articles of Dissociation:
1. The name of the organization is:
__________________________________________
2. Date of filing Articles of Organization or
Certificate of Authority with the West
Virginia Secretary of State’s Office:
__________________________________________
3. The name(s) and address(es) of the person(s) being dissociated from the company:
Name
Address
City, State, Zip Code
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
4. Contact name and phone number to reach in case of a problem with filing: (Optional, however,
listing one may help to avoid a return or rejection of filing if there is a problem with the document.)
____________________________________________ ____________________________________
Contact Name
Phone Number
Business e-mail address, if any: _______________________________________________________
Signature of person executing document *
5.
(See below Important Legal Notice Regarding Signature):
Signature: _____________________________________
Title: __________________________
*Important Legal Notice Regarding Signature: Per West Virginia Code §31B-2-209. Liability for false
statement in filed record. If a record authorized or required to be filed under this chapter contains a false statement,
one who suffers loss by reliance on the statement may recover damages for the loss from a person who signed the
re
cord or caused another to sign it on the person's behalf and knew the statement to be false at the time the record was signed.
Form LLD-F-2
Issued by the Office of the Secretary of State
Revised 5/13