ROSS MILLER Secretary of State 204 North Carson Street, Suite 1 Carson City, Nevada 89701-4520 (775) 684 5708 Website: www.nvsos.gov
Statement of Dissociation
(PURSUANT TO NRS 87.4349)
USE BLACK INK ONLY - DO NOT HIGHLIGHT
ABOVE SPACE IS FOR OFFICE USE ONLY
Statement of Dissociation (Pursuant to NRS 87.4349)
1. Name of partnership currently on file:
2. Statement of Partnership Authority date:
and file number:
3. Name as set forth in Statement of Partnership Authority, if different from current name:
4. The following partner is dissociated from the above named partnership:
5. Declaration and Signature:
I declare, to the best of my knowledge under penalty of perjury, that the above mentioned entity has complied with the provisions of NRS 360.780 and acknowledge that pursuant to NRS 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing in the Office of the Secretary of State.
Signature of Partner (as authorized by NRS 87.4301 to 87.4357)
Filing Fee: $50.00
IMPORTANT: Failure to include any of the above information and submit with the proper fees may cause this filing to be rejected.
This form must be accompanied by appropriate fees.
Nevada Secretary of State SPA Dissociation Revised: 5-15-09