Free 51989-06-06.xft - North Dakota

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(If paying with credit card complete authorization at bottom of page 2)

CERTIFICATE OF WITHDRAWAL FOREIGN LIMITED LIABILITY COMPANY APPLICATION
SECRETARY OF STATE
SFN 51989 (06-2006)

FOR OFFICE USE ONLY ID#: WO#: Filed: By:

1. FILING FEE $20.00
SEE REVERSE SIDE FOR FEES, FILING AND MAILING INSTRUCTIONS. This form is prescribed for use by a foreign limited liability company or a foreign professional limited liability company. The following statements are hereby submitted for Certificate of Withdrawal from the State of North Dakota. TYPE OR PRINT LEGIBLY 2. The name of the limited liability company: For reference, see North Dakota Century Code, Section 10-32-143.

3. Federal ID #:

4. State or country where organized:

5. An address to which a person may mail a copy of any process against the limited liability company: (Street/RR, PO Box, City, State, Zip+4)

6. "The following is hereby affirmed: The limited liability company is not transacting business or conducting activities in North Dakota and surrenders its authority to do so. The limited liability company revokes the authority of its registered agent in North Dakota to accept service of process. The limited liability company consents to service of process on the limited liability company by service upon the North Dakota Secretary of State in any action, suit, or proceeding based upon any cause of action arising in North Dakota during the time the limited liability company was authorized to transact business or conduct activities. The undersigned, a person authorized by the limited liability company to sign this application, knows the contents of the application, and believes the statements made to be true." Signature:

Date:

7. Name of person to contact about this application:

E-Mail Address:

Daytime Telephone #:

SFN 51989 (06-2006) Page 2

INSTRUCTIONS FOR CERTIFICATE OF WITHDRAWAL FOREIGN LIMITED LIABILITY COMPANY APPLICATION
A foreign limited liability company may apply for a Certificate of Withdrawal when it ceases to transact business or conduct activities in the State of North Dakota. The Certificate of Withdrawal may invalidate any other licenses or permits the limited liability company may have acquired. The following numbers correspond to the numbered sections on the front of this form. 1. FILING FEE: The application filing fee is $20.00. (A check must be payable to "Secretary of State" and must be for U.S. negotiable funds. Payments may also be made by credit card using Visa, Master Card or Discover.) 2. Provide the limited liability company name as provided in the Certificate of Authority issued by the North Dakota Secretary of State. (Punctuation and abbreviations must be consistent with that as authorized.) 3. To properly maintain limited liability company records, the Federal ID number is required. Privacy: In compliance with N.D.C.C., Section 10-32-153.1, social security numbers and Federal ID numbers are not disclosed to the public. They are used by the Secretary of State to maintain accurate limited liability company files. Therefore, while voluntary disclosure is requested, failure to do so will not result in rejection of the registration. 4. Identify the state or country in which the limited liability company is organized. 5. Provide an address to which a person may mail a copy of any process against the limited liability company. In this section, an address must include a street or rural address, a post office box number if applicable, and the city, state, and zip code plus 4-digit extension. 6. As required by North Dakota law, the application includes the following statements which are affirmed by signing the application: a) The limited liability company is not transacting business or conducting activities in North Dakota. b) The limited liability company revokes the authority of its registered agent in North Dakota. The limited liability company consents to service of process on the limited liability company by service upon the North Dakota Secretary of State in any action, suit, or proceeding based upon any cause of action arising in North Dakota during the time the limited liability company was authorized to transact business or conduct activities. This application must be dated and bear the signature of an individual authorized to sign on behalf of the limited liability company. 7. Provide the name, email address, and daytime telephone number of the person to contact for any issues related to this application.

ASSISTANCE: If assistance is required to complete the application for Certificate of Withdrawal, contact the Secretary of State's Office. EXPEDITING PROCESS: Be sure to complete number 7. If the application is being submitted by someone other than the limited liability company, provide a cover letter with the name and telephone number of the responsible individual so that any deficiencies can be remedied by telephone. FAX FILING: Documents and Credit Card Payment Authorization may be faxed to 701-328-2992. A faxed filing does not expedite the process of the application in the office of the Secretary of State. EMAIL: Email is not a secure utility for the transmission of private information or credit card authorizations. DO NOT EMAIL YOUR DOCUMENT TO THE SECRETARY OF STATE. MAILING INSTRUCTIONS: Send an application AND filing fee to: Secretary of State State of North Dakota 600 E Boulevard Ave Dept 108 Bismarck ND 58505-0500

Telephone: 701-328-4284

Toll Free: 800-352-0867 (8-4284)

Fax: 701-328-2992 Home Page: www.nd.gov/sos

CREDIT CARD PAYMENT AUTHORIZATION
SECRETARY OF STATE
SFN 51478 (06-03) (All items required to complete transaction) Name: Address: VISA Account Number: Master Card Discover V# Card Expires: Month Year City: State: Zip Code:

Signature: (Required by credit card companies)

Date: