Application For Certificate Of Authority Limited Liability Company (Page 6 of 6) in pdf

Application For Certificate Of Authority Limited Liability Company Page 6

Page 2

APPLICATION FOR CERTIFICATE OF AUTHORITY

LIMITED LIABILITY COMPANY

Page 2 of 2

(ss-4233)

For Office Use Only

Business Services Division

Tre Hargett, Secretary of State

State of Tennessee

312 Rosa L. Parks AVE, 6th Fl.

Nashville, TN 37243-1102

(615) 741-2286

Filing Fee: $50.00 per member

(minimum fee = $300, maximum fee = $3,000)

The name of the Limited Liability Company is:

11. The complete mailing address of the entity (If different from the principal office) is:

Address:

City:

State:

Zip Code:

12. Non-Profit LLC (required only if the Additional Designation of “Non-Profit LLC” is entered in section 3.)

I certify that this entity is a Non-Profit LLC whose sole member is a nonprofit corporation, foreign or domestic, incorporated

under or subject to the provisions of the Tennessee Nonprofit Corporation Act and who is exempt from franchise and excise

tax as not-for-profit as defined in T.C.A. §67-4-2004. The business is disregarded as an entity for federal income tax purposes.

13. Professional LLC (required only if the Additional Designation of “Professional LLC” is entered in section 3.)

I certify that this PLLC has one or more qualified persons as members and no disqualified persons as members or holders.

I certify that this entity meets the requirement of T.C.A. §48-249-1123(b)(3)

Licensed Profession:

14. Series LLC (required only if the Additional Designation of “Series LLC” is entered in section 3.)

I certify that this entity meets the requirements of T.C.A. §48-249-309(i)

If the provisions of T.C.A. §48-249-309(i) (relating to foreign series LLCs) apply, then the information required by that section

should be attached as part of this document.

15. Obligated Member Entity (list of obligated members and signatures must be attached)

This entity will be registered as an Obligated Member Entity (OME)

Effective Date:

Month

Day

Year

I understand that by statute: THE EXECUTION AND FILING OF THIS DOCUMENT WILL CAUSE THE MEMBER(S) TO BE

PERSONALLY LIABLE FOR THE DEBTS, OBLIGATIONS AND LIABILITIES FOR THE LIMITED LIABILITY COMPANY TO

THE SAME EXTENT AS A GENERAL PARTNER OF A GENERAL PARTNERSHIP. CONSULT AN ATTORNEY.

16. Other Provisions:

Signature Date

Signature

Signer’s Capacity (if other than individual capacity)

Name (printed or typed)

Rev. 10/12

RDA 2458

Application For Certificate Of Authority Limited Liability Company Page 6

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