State of Missouri
D WE S T ITE
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Robin Carnahan, Secretary of State
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Registration Number of fictitious name, filed with our office, to be cancelled: X Name of fictitious name, filed with our office, to be cancelled: Business address of above listed fictitious name registration at time of filing to be cancelled
In Affirmation thereof, the facts stated above are true and correct: (The undersigned understands that false statements made in this filing are subject to the penalties provided under Section 575.060 RSMo)
Authorized Signature
Authorized Signature
Authorized Signature
Name and address to return filed document: Name: Address: City, State, and Zip Code:
Corp. 14 (11/2008)
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Corporations Division PO Box 778 / 600 W. Main St., Rm. 322 Jefferson City, MO 65102
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Cancellation of Registration of Fictitious Name
(No Fee Required)
Signature of at least one owner as listed on fictitious name to be cancelled
Printed Name
Date
Printed Name
Date
Printed Name
Date