Arkansas Secre t a ry of State
State Capitol · Little Rock, Arkansas 72201-1094 501-682-3409 · www.sos.arkansas.gov
Business & Commercial Services, 250 Victory Building, 1401 W. Capitol, Little Rock
Instructions: File with the Arkansas Secretary of State's Business Services Division, State Capitol, Little Rock, Arkansas 72201-1094 with payment of fees. A copy will be returned to the partnership at the listed address.
PLEASE TYPE OR CLEARLY PRINT IN INK
STATEMENT OF DISSOCIATION
The undersigned, pursuant to Act 1518 of 1999, sets forth the following:
Name of Partnership:
Name of Dissociated Partner:
Mailing Address of Dissociated Partner:
Effective Date of Dissociation:
I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days.
Authorizing Offficer (Type or Print)
Filing Fee $15.00 payable to Arkansas Secretary of State