Application For Cancellation Of Certificate Of Authority {SS-4241}

For Office Use Only APPLICATION FOR CANCELLATION OF CERTIFICATE OF AUTHORITY Corporate Filings (LIMITED LIABILITY COMPANY) 312 Eighth Avenue North th 6 Floor, William R. Snodgrass Tower Nashville, TN 37243 To the Secretary of State of the State of Tennessee: Pursuant to the provisions of 48-246-401 of the Tennessee Limited Liability Company Act, the under- signed Limited Liability Company hereby applies for a certificate of cancellation form the State of Tennes- see, and for that purpose sets forth: 1. The name of the Limited Liability Company is _______________________________________________________ ________________________________________________________________________________________________. If different, the name under which the certificate of authority was obtained is _________________________________________________________________________________________________. 2. The state or country under whose law it is organized is ____________________________________________. 3. The Limited Liability Company is not transacting business in the State of Tennessee and surrenders its authority to transact business in this state. 4. Indicate which of the following statements apply by marking the applicable box: The Limited Liability Company continues its registered agent and registered office in the State of Tennessee. The Limited Liability Company hereby revokes the authority of its registered agent to accept service on its behalf and appoints the Secretary of State as its agent for service of process in any proceeding based on a cause of action arising during the time it was authorized to transact business in this state. 5. The mailing address (including zip code) to which the Secretary of State may mail a copy of any process served on him is __________________________________________________________________________________________________. 6. The undersigned Limited Liability Company makes the commitment to notify the Secretary of State in the future of any change in its mailing address. ____________________________________________________________________________________________ Signature Date Name of Limited Liability Company ____________________________________________________________________________________________ Signers Capacity Signature __________________________________________________ Name (typed or printed) SS-4241 (Rev. 10/03) Filing Fee: $20 RDA 2458