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Articles Of Conversion

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State of Utah

Department of Commerce

Division of Corporations & Commercial Code

Statement of Dissolution

Clear Form

Limited Liability Company Name: _____________________________________________________________

Entity Number: _______________________

The dissolution of above named limited liability company will become effective:

upon filing with the Division of Corporations and Commercial Code.

the future effective date of _____________________________.

Under penalties of perjury, I declare that this Statement of Dissolution has been examined by me and is, to the

best of my knowledge and belief, true, correct and complete.

Sign here after the form is printed

By: _______________________________________ Name: _________________________________________

Select one of the following from this drop down field:

Capacity: ____________________________________________________________ Date: ________________

Additional filing requirements:

If the filer requests a copy of the Statement of Dissolution an additional exact copy of the filed document along

with a return-addressed envelope with adequate first-class postage must also be submitted.

Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you

may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity.

/contactus.html

Division's Website:

Mailing/Faxing Information:

06/16

Articles Of Conversion

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