LLC-45.40
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Illinois
FILE #
Form
Limited Liability Company Act
This space for use by Secretary of State.
July 2017
Application for Withdrawal
Secretary of State
Department of Business Services
Limited Liability Division
SUBMIT IN DUPLICATE
501 S. Second St., Rm. 351
Type or print clearly.
Springfield, IL 62756
217-524-8008
Filing Fee:
$5
Payment may be made by check
Approved:
payable to Secretary of State. If
check is returned for any reason this
filing will be void.
1. Limited Liability Company name: ____________________________________________________________________
______________________________________________________________________________________________
2. State or country of organization: ___________________________________________________________________
3. Street address to which a copy of any process against the company served on the Secretary of State may be mailed:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. The company is not transacting business in Illinois.
5. The company surrenders its admission to transact business in Illinois.
6. The company revokes the authority of its registered agent in Illinois and consents that service of process may hereafter be
made on the company by service thereof upon the Secretary of State.
7. The undersigned affirms, under penalties of perjury, having authority to sign hereto, that this application for withdrawal is
to the best of my knowledge and belief, true, correct and complete.
Dated
_________________________________, _______________
Month & Day
Year
______________________________________________________________
Signature
______________________________________________________________
Name and Title (type or print)
______________________________________________________________
If applicant is signing for a company or other entity,
RETURN TO: (Please type or print clearly.)
state name of company or entity.
___________________________________________________________
Name
___________________________________________________________
Street
___________________________________________________________
City, State, ZIP Code
Printed by authority of the State of Illinois.
2017 — 1 — LLC 10.9
December