Form 635_08_2 - Statement Of Cancellation

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MATT SCHULTZ
STATEMENT OF
Secretary of State
CANCELLATION
State of Iowa
TO THE SECRETARY OF STATE OF THE STATE OF IOWA:
Pursuant to section 807 of the Iowa Revised Limited Liability Companies Act, the undersigned limited liability
company states:
1.
The name of the Limited Liability Company: __________________________________________
and the name the Limited Liability Company uses in Iowa if different than its real name:
____________________________________________________________________________
2.
The Limited Liability Company is formed under the laws of the state [or foreign country] of:
____________________________________________________________________________
3.
The Limited Liability Company desires to cancel its certificate of authority in Iowa.
4.
The Limited Liability Company revokes the authority of its registered agent to accept service on its
behalf and appoints the Secretary of State as its agent for service of process in any proceeding based
on a cause of action arising during the time it was authorized to transact business in Iowa.
5.
The mailing address to which the Secretary of State may mail a copy of any process served on the
Secretary of State is:
Name ________________________________________________________________________
Address ______________________________________________________________________
City, State, ZIP ________________________________________________________________
(The Limited Liability Company will notify the Secretary of State of any changes in this mailing address.)
Signature _________________________________________________ Date ________________
Type or print name and title _______________________________________________________
The filing fee is $10.00.
635_08_2
rev. 12/11

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