Free Fillable Certificate of Surrender of Authority Form - New York

New York State Department of State Division of Corporations, State Records and Uniform Commercial Code One Commerce Plaza, 99 Washington Avenue Albany, NY 12231 www.dos.state.ny.us

CERTIFICATE OF SURRENDER OF AUTHORITY OF
(Insert Name of Foreign Limited Liability Company)

Under Section 806 of the Limited Liability Company Law

FIRST: The name of the limited liability company as it appears on the index of records in the
Department of State is: If applicable: the fictitious name the foreign limited liability company has agreed to use in New York State is:

SECOND: The jurisdiction of organization of the foreign limited liability company is: THIRD: The date on which its certificate of authority to do business in this state was filed
with the Department of State is: York State.

FOURTH: The limited liability company surrenders its authority to do business in New FIFTH: The limited liability company hereby revokes the authority of its registered agent, if

any, previously designated and it hereby consents that process against it in any action or special proceeding based upon any liability or obligation incurred by it within this state before the filing of the certificate of surrender may be served on the Secretary of State in the manner set forth in Article 3 of the Limited Liability Company Law.

SIXTH: The address within or without this state to which the Secretary of State shall mail a
copy of any process against the limited liability company served upon him or her is:

X

(Signature) (Type or Print Name of Signer) (Title of Signer)

DOS-1379 (Rev. 5/08)

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CERTIFICATE OF SURRENDER OF AUTHORITY OF
(Insert Name of Foreign Limited Liability Company)

Under Section 806 of the Limited Liability Company Law

Filed by:

(Name)

(Mailing address)

(City, State and ZIP code)

NOTE: This form was prepared by the New York State Department of State for filing a certificate of surrender of authority for a foreign limited liability company. It does not contain all optional provisions under the law. You are not required to use this form. You may draft your own form or use forms available at legal supply stores. The Department of State recommends that legal documents be prepared under the guidance of an attorney. The certificate must be submitted with a $60 filing fee made payable to the Department of State.
(For office use only)

DOS-1379 (Rev. 5/08)

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