JAY DARDENNE SECRETARY OF STATE
STATE OF LOUISIANA SECRETARY OF STATE
Commercial (225) 925-4704 (225) 922-0435 Fax Administrative Services (225) 925-4704 (225) 925-4726 Fax Uniform Commercial Code (225) 922-1193 (225) 922-0452 Fax
TRANSMITTAL INFORMATION For All Business Filings
Business Name (List exactly as it appears in documents)
Name of person filing document (evidence of filing will be mailed to this person, at address below)
Daytime phone number
NOTE: Louisiana Law requires all Louisiana notaries to print or type their name and notary or bar roll number on the document.
Mailing Address: P. O. Box 94125, Baton Rouge, LA * 70804-9125 Office Location: 8585 Archives Ave., Baton Rouge, LA * 70809 Web Site Address: www.sos.louisiana.gov
SS984 Rev. 10/08
Jay Dardenne Secretary of State
AFFIDAVIT TO DISSOLVE CORPORATION
(R.S. 12:142.1 & 12:250.1) Domestic Corporation (Business or Non-Profit) Enclose $60.00 filing fee Make remittance payable to Secretary of State Do Not Send Cash Return to: Commercial Division P. O. Box 94125 Baton Rouge, LA 70804-9125 Phone (225) 925-4704 Web Site: www.sos.louisiana.gov
STATE OF PARISH/COUNTY OF
BEFORE ME, the undersigned Notary Public in and for the parish/county herein above shown, personally came and appeared the undersigned who, after being duly sworn, did depose and say that:
is no longer doing business, owes no debts and owns no immovable property is dissolved by filing this affidavit with the Secretary of State, executed by the shareholder(s), or incorporator(s) if no shares have been issued, attesting to such facts.
The undersigned further declared that they are: (check one) ( ) ( ) The shareholders of the above named corporation. The incorporators of the above named corporation and no shares have been issued.
Incorporator(s) or Shareholder(s) Signature(s) Sworn to and subscribed before me, the undersigned Notary Public, on this date: NOTARY NAME MUST BE TYPED OR PRINTED WITH NOTARY #
SS339 Rev. 03/08
(See instructions on back)
File this form, along with the appropriate filing fee with the Secretary of State's office. You will receive two Certificates of Dissolution, one copy of which should be filed with the Clerk of Court where the corporation maintains its registered office. If the corporation's registered office is located in Orleans Parish, a Certificate of Dissolution must be filed with the recorder of mortgages.