Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605)773-4845
STATEMENT OF DISSOCIATION
DOMESTIC LIMITED LIABILITY COMPANY
Please Type or Print Clearly in Ink
Clear Form
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Telephone # ____________________ FAX # _______________________
Please submit one Original and one Photocopy
FILING FEE: $10 payable to SECRETARY OF STATE
The undersigned hereby files this statement of dissociation pursuant to SDCL 47-34A-605.
1. The name of the company is ______________________________________________________________________ ______________________________________________________________________________________________
Note: This must be the exact limited liability company name.
2. The name of the member dissociated from the company is _______________________________________________
3. A copy of this statement has been delivered to the limited liability company
Dated ____________________________
______________________________________________
(Signature)
______________________________________________
(Printed Name)
______________________________________________
(Title)
domesticllcstatemenofdissociation July 2008