Free STATE OF SOUTH CAROLINA - South Carolina

STATE OF SOUTH CAROLINA SECRETARY OF STATE MEMBERS STATEMENT OF DISSOCIATION FROM A LIMITED LIABILITY COMPANY
TYPE OR PRINT CLEARLY IN BLACK INK

The following member of the Limited Liability Company hereby files this statement of Dissociation in accordance with Section 33-44-704 of the 1976 South Carolina Code of Laws, as amended. 1. Name of the Limited Liability Company from which a member has dissociated: ________________________________________________________________________________

2. Name of member who has dissociated from the Limited Liability Company: ________________________________________________________________________________ ________________________________________________________________________________
Street Address

________________________________________________________________________________
City State Zip Code

3. Unless otherwise specified, this statement is effective when endorsed for filing by the Secretary of State. Specify any delayed effective date and time: ________________________________________________________________________________

4. This statement is being filed by: [ ] a. The dissociating member: ________________________________________
Signature of member Date

[ ]

b.

The Limited Liability Company: ________________________________________
Signature Date

________________________________________
Name Capacity

FILING INSTRUCTIONS 1. 2. File two copies of this form, the original and either a duplicate original or a conformed copy. If space in this form is insufficient, please attach additional sheets containing a reference to the appropriate paragraph in this form, or prepare this using a computer disk, which will allow for expansion of space on this form. This form must be accompanied by the filing fee of $2.00 payable to the Secretary of State. Return to: Secretary of State P.O. Box 11350 Columbia, SC 29211 Form Revised by South Carolina Secretary of State, January 2000

3.