PENNSYLVANIA DEPARTMENT OF STATE
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
Return document by mail to:
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Address
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Return document by email to:
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Fee: $70
Check one:
From General Partnership (§ 8474)
From Limited Partnership (§ 8665)
In compliance with the requirements of 15 Pa.C.S. § 8474 or 8665 (relating to certificate of dissociation), the
undersigned person dissociated as a partner, hereby states that:
1. The name of the general or limited partnership is: ___________________________________________________
2. Complete part (a) OR (b) – not both:
(a) The partnership is a domestic general partnership or limited liability partnership and the address, including number
and street, if any, of its principal place of business is:
____________________________________________________________________________________________________
Number and street of principal office
City
State
Zip
County
(b) The partnership is a domestic limited partnership or limited liability limited partnership, and the (1) address of its
current registered office in this Commonwealth or (2) name of its commercial registered office provider and the county
of venue is: (Complete (1) or (2), not both)
(1) _________________________________________________________________________________________________
Number and Street
City
State
Zip
County
(2) _________________________________________________________________________________________________
Name of Commercial Registered Office Provider
County
3. The name of the person who has dissociated from the partnership: _____________________________________
4. Check one. The person named in field 3 has:
Dissociated from the general partnership.
Dissociated as a general partner from the limited partnership.
IN TESTIMONY WHEREOF, the undersigned person has caused this Certificate of Dissociation to be executed this
___________ day of ___________________________, 20
.
___________________________________________________________
Name of Person
___________________________________________________________
Signature
___________________________________________________________
Title