FOREIGN LIMITED LIABILITY COMPANY
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
Wyoming Secretary of State
Phone (307) 777-7311/7312
The Capitol Building, Room 110
Fax (307) 777-5339
200 W. 24th Street
E-mail: corporations@state.wy.us
Cheyenne, WY 82002-0020
Pursuant to W.S. 17-16-1520 of the Wyoming Business Corporation Act, the undersigned limited
liability company hereby applies for a Certificate of Withdrawal from the state of Wyoming, and for that
purpose submits the following statement:
FIRST:
The name of the limited liability company is: ____________________________________
_____________________________________________________________________
SECOND: It is organized under the laws of: _____________________________________________
THIRD:
It is no longer transacting business in this state; and it hereby surrenders its authority to
transact business in the state of Wyoming.
FOURTH: It 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 arising during the time it was authorized to transact business in this
state.
FIFTH:
A mailing address to which the Secretary of State may mail a copy of any process served
on him under Item Four: ___________________________________________________
_____________________________________________________________________
SIXTH:
It will notify the Secretary of State in the future of any change in its mailing address.
Date: __________________________
Signed: ____________________________________
Title: ______________ _______________________
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Filing Fee:
$50.00
1.
The document shall be executed by a member,manager, or other authorized individual as set
forth in the operating agreement.
2.
The document shall be accompanied by one (1) exact or photo copy
llwithd - Revised: 9/2003