Free 635_08_2.p65 - Iowa

MICHAEL A. MAURO Secretary of State State of Iowa
TO THE SECRETARY OF STATE OF THE STATE OF IOWA:

STATEMENT OF CANCELLATION

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. 12/08

NOTES:

1. The filing fee is $10.00. Make checks payable to Secretary of State.

2. The form must be signed by a person authorized by the company. A copy of a signature is acceptable for filing.

3. One copy of the document is to be delivered to the Secretary of State for filing.

4. The effective time and date of the document is the later of the following: a. the time of filing on the date it is filed; b. the time specified in the document on the date it is filed; c. the time and date specified in the document, not later than 90 days after the date it is filed.

5. The information you provide will be open to public inspection under Iowa Code section 22.11.

SECRETARY OF STATE Business Services Division Lucas Building, 1st Floor Des Moines, Iowa 50319 Phone: (515) 281-5204 FAX: (515) 281-7142 or (515) 242-5953 Website: www.sos.state.ia.us