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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)

Address

City

State

Zip Code

Daytime phone number

Fax number

Email address

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

APPLICATION FOR WITHDRAWAL OF A FOREIGN CORPORATION/ LIMITED LIABILITY COMPANY FROM THE STATE OF LOUISIANA (R. S. 12:312 & 12:1351)
Enclose $100 (Corporation) filing fee Return to: $125 (Limited Liability Company) filing fee Make remittance payable to Secretary of State Do Not Send Cash 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

Company Name organized under the laws of the state of is no longer transacting business in the State of Louisiana, effective surrenders its authority to transact business in the state of Louisiana; revokes the authority of its registered agent to accept service of process, and consents that service of process in any action or proceeding based on any cause of action arising out of or resulting from or connected with any business transacted by it in this State during the time the company was authorized to transact business in this State, be made on the company by service thereof on the Secretary of State, or on a person in his office designated to receive service of process; such service, if made on the Secretary of State. , county of

Officer/Manager or Member

Date

Sworn to and subscribed before me, the undersigned Notary Public, on this date:

Notary

SS338 Rev. 11/08

(see instructions on back)

INSTRUCTIONS

1.

A foreign corporation or limited liability company authorized to transact business in this state may withdraw from this state upon procuring from the Secretary of State a Certificate of Withdrawal. In order to obtain a Certificate of Withdrawal, this application must be executed in duplicate by any officer for a corporation, or by a manager, if management of the limited liability company is vested in one or more managers, or a member, if management is reserved to the members, for a limited liability company. The application must be acknowledged by the signing party before a notary public. (If the withdrawal is for a corporation which is in the hands of a receiver or a trustee, this form shall be executed on behalf of the corporation by such receiver or trustee and acknowledged by him.) A Certificate of Withdrawal shall be issued when all fees, charges, taxes, unemployment compensation, distributions and interest have been paid as required by law and evidenced by certificates of the Collector of Revenue and the Administrator of the Division of Employment Security of the Department of Labor. (The Secretary of State's office requests these Certificates from the above offices.) Upon the issuance of a Certificate of Withdrawal, the authority of the company to transact business in Louisiana shall cease.

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