Form Ss-4241 - Llc - Application For Cancellation Of Certificate Of Authority - State Of Tennessee

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For Office Use Only
APPLICATION FOR CANCELLATION
OF CERTIFICATE OF AUTHORITY
Corporate Filings
(LIMITED LIABILITY COMPANY)
312 Eighth Avenue North
6 th Floor, William R. Snodgrass Tower
Nashville, TN 37243
To the Secretary of State of the State of Tennessee:
Pursuant to the provisions of §48-246-401 of the Tennessee Limited Liability Company Act, the under-
signed Limited Liability Company hereby applies for a certificate of cancellation form the State of Tennes-
see, and for that purpose sets forth:
1. The name of the Limited Liability Company is _______________________________________________________
________________________________________________________________________________________________.
If different, the name under which the certificate of authority was obtained is
_________________________________________________________________________________________________.
2. The state or country under whose law it is organized is ____________________________________________.
3. The Limited Liability Company is not transacting business in the State of Tennessee and surrenders its
authority to transact business in this state.
4. Indicate which of the following statements apply by marking the applicable box:
The Limited Liability Company continues its registered agent and registered office in the State of
Tennessee.
The Limited Liability Company hereby 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 this state.
5. The mailing address (including zip code) to which the Secretary of State may mail a copy of any process
served on him is
__________________________________________________________________________________________________.
6. The undersigned Limited Liability Company makes the commitment to notify the Secretary of State in the
future of any change in its mailing address.
__________________________________________
__________________________________________________
Signature Date
Name of Limited Liability Company
__________________________________________
__________________________________________________
Signer’s Capacity
Signature
__________________________________________________
Name (typed or printed)
SS-4241 (Rev. 10/03)
Filing Fee: $20
RDA 2458

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