Form Llc-45.40 - Application For Withdrawal - Foreign

Illinois

LLC-45.40

This space for use by

Form

Secretary of State

Limited Liability Company Act

January 1999

APPLICATION FOR WITHDRAWAL – FOREIGN

Jesse White

Secretary of State

Department of Business Services

Limited Liability Company Division

Submit in Duplicate

Room 359, Howlett Building

Must be typewritten

Springfield, IL 62756

This space for use by Secretary of State

http:

Date

Payment may be made by business

Assigned File #

firm check payable to Secretary of

Filing Fee

$100

State. (If check is returned for any

Approved:

reason this filing will be void.)

1. Limited Liability Company name: __________________________________________________________________

_____________________________________________________________________________________________

2. File number assigned by the Secretary of State: ______________________________________________________

3. Federal Employer Identification Number (F.E.I.N.): ____________________________________________________

4. State or Country of organization: __________________________________________________________________

5. Street address to which may be mailed a copy of any process against the limited liability company that may be served

on the Secretary of State.

_____________________________________________________________________________________________

6. The company is not transacting business in Illinois.

7. The company surrenders its admission to transact business in Illinois.

8. The company revokes the authority of its registered agent in Illinois and consents that service of process may hereafter

be made on the company by service thereof upon the Secretary of State.

9. The undersigned affirms, under penalties of perjury, having authority to sign hereto, that this application for withdrawal

is to the best of my knowledge and belief, true, correct and complete.

Dated _______________________________ , _____.

(Month & Day)

(Year)

_______________________________________________

(Signature)

_______________________________________________

(Type or print Name and Title)

_______________________________________________

(If applicant is a company or other entity, state name of company

and indicate whether it is a member or manager of the LLC.)

LLC-10.2

Form Llc-45.40 - Application For Withdrawal - Foreign - 1999

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