Free AT 04.p65 - Kansas

Contact Information
Kansas Secretary of State Ron Thornburgh Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-4564 [email protected] www.kssos.org

KANSAS SECRETARY OF STATE

Certificate of Amendment/Termination to Certificate of LLC Merger or Consolidation
All information must be completed or this document will not be accepted for filing.

AT
53-14

Print

Reset

1. Identify the certificate of merger or consolidation and the agreement of merger or consolidation affected:

Please complete the form, print, sign and mail to the Kansas Secretary of State with the filing fee. Selecting 'Print' will print the form and 'Reset' will clear the entire form.
Do not write in this space

2. State whether the agreement of merger or consolidation has been amended or terminated.

____ Amended

____ Terminated

3. If the merger has been amended, state the amendment to the certificate of merger:

I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct. Executed on the
Day

of
Month

,
Year

.

Authorized person

Instructions 1. This certificate may only be filed if the certificate of merger or consolidation provided for a future
effective date and this certificate is filed prior to the effective date.
2. Submit this form with the $35 filing fee. Notice: There is a $25 service fee for all returned checks.

Rev. 12/06/04 amc Rev. 8/11/03 jb K.S.A. 17-7681