Form Dos-1379-F - Certificate Of Surrender Of Authority
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1
2New York State
Department of State
DIVISION OF CORPORATIONS,
STATE RECORDS AND
UNIFORM COMMERCIAL CODE
One Commerce Plaza
99 Washington Ave.
Albany, NY 12231-0001
CERTIFICATE OF SURRENDER OF AUTHORITY
OF
(Insert Name of Foreign Limited Liability Company)
Under Section
of the Limited Liability Company Law
806
FIRST:
The name of the foreign limited liability company as it appears on the index of names in the
Department of State is:
.
If applicable: the fictitious name the foreign limited liability company has agreed to use in New York State is:
.
SECOND:
The jurisdiction of organization of the foreign limited liability company is:
.
THIRD:
The date on which its application for authority to do business in this state was filed with the
Department of State is:
.
FOURTH:
The foreign limited liability company surrenders its authority to do business in New York State.
FIFTH:
The foreign limited liability company hereby revokes the authority of its registered agent, if any,
previously designated and it hereby consents that process against it in any action or special proceeding based
upon any liability or obligation incurred by it within this state before the filing of the certificate of surrender
of authority may be served on the Secretary of State in the manner set forth in Article 3 of the Limited
Liability Company Law.
SIXTH:
The address within or without this state to which the Secretary of State shall mail a copy of any
process against the foreign limited liability company served upon him or her is:
.
Capacity of signer
:
(Check appropriate box)
X
(Signature)
Member
Manager
(Type or Print Name of Signer)
Authorized Person
Page 1 of 2
DOS-1379-f (Rev. 03/17)
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