Form Ss-4241 - Application For Cancellation Of Certificate Of Authority

Form Ss-4241 - Application For Cancellation Of Certificate Of Authority - 1999

For Office Use Only

APPLICATION FOR CANCELLATION

OF CERTIFICATE OF AUTHORITY

Corporate Filings

(LIMITED LIABILITY COMPANY)

312 Eighth Avenue North

6 th 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

__________________________________________

__________________________________________________

Signer’s Capacity

Signature

__________________________________________________

Name (typed or printed)

SS-4241 (Rev. 3/99)

RDA 2458

Form Ss-4241 - Application For Cancellation Of Certificate Of Authority - 1999