State of New Hampshire 
 
               APPLICATION FOR CERTIFICATE OF CANCELLATION OF 
 REGISTRATION OF FOREIGN LIMITED LIABILITY COMPANY 
 
SECRETARY OF STATE’S CANCELLATION FILING REQUIREMENTS: 
 
1.  Obtain original tax certificate from the N.H. Dept. of Revenue Administration. 
 
 To obtain this tax certificate, Certificate Request Form AU-22 must be completed and submitted 
 to the N.H. Dept. of Revenue Administration.  Follow this link to obtain the required form:  
 http://revenue.nh.gov/forms/2013/documents/au-22.pdf 
 
2.  Mail completed Form FLLC-3 with original tax certificate from the Dept. of Revenue Administration and 
 $35.00 filing fee to: 
 
 Corporation Division 
 Dept of State 
 107 N Main St 
 Concord  NH  03301-4989 
 
 OR, deliver the paperwork in person to: 
 
 State House Annex, 3rd Floor, Rm 317 
 25 Capitol St 
 Concord, NH 
 
  Mailing Address - Corporation Division, NH Dept. of State, 107 N Main St, Rm 204, Concord, NH 03301-4989 
 Physical Location - State House Annex, 3rd Floor, Rm 317, 25 Capitol St, Concord, NH 
 
                                                                                   Form FLLC-3  (Instruct.) 

Print Reset
                         State of New Hampshire 
 
Filing fee: $35.00                                                                               Form FLLC-3 
Use black print or type.                                                                         RSA 304-C:179 
 
                   APPLICATION FOR CERTIFICATE OF CANCELLATION OF 
                   REGISTRATION OF FOREIGN LIMITED LIABILITY COMPANY 
 
PURSUANT TO THE PROVISIONS of Chapter 304-C, Section 179 of the New Hampshire Revised 
Statutes Annotated, the undersigned hereby applies for a Certificate of Cancellation of Registration, and 
for that purpose submits the following statement: 
 
FIRST:  The name of the limited liability company is                                                                               
                                                                                                                                  . 
 
SECOND:  It is formed under the laws of                                      . 
 
THIRD:  It is not doing business in New Hampshire. 
 
FOURTH:  It hereby surrenders its certificate of registration to transact business in New Hampshire. 
 
FIFTH:  It revokes the authority of its registered agent for service of process in this state and consents 
that service of process in any action, suit, or proceeding based upon any cause of action arising in this 
state during the time it was authorized to do business in this state may thereafter be made on it by service 
thereof upon the secretary of state. 
 
SIXTH:  The mailing address to which a person may mail a copy of any process against the limited 
liability company that may be served on him is                                                                                     
                                                                                                                                  . 
 
SEVENTH:  The limited liability company is in good standing as evidenced by the filing of all annual 
report(s) due. 
 
EIGHTH:  A statement is attached from the New Hampshire Department of Revenue Administration that 
all taxes due from or accrued by the limited liability company through the date of the application for a 
certificate of cancellation of registration have been either assessed and paid or adequately provided for in 
a manner acceptable to the New Hampshire Department of Revenue Administration. 
 
                                          *Signature:                                                                              
                                     Print or type name:                                                                           
                                                         Title:                                                                    
                                          Date signed:                                                                             

*  Shall be executed on behalf of the foreign limited liability company by a person with authority to do so under the 
      laws of the state or other jurisdiction of its formation, or, if the foreign limited liability company is in the hands of a 
      receiver, executor, or other court appointed fiduciary, trustee, or other fiduciary, it must be signed by that fiduciary. 
 
DISCLAIMER:  All documents filed with the Corporation Division become public records and will be available for 
public inspection in either tangible or electronic form. 
 
  Mailing Address - Corporation Division, NH Dept. of State, 107 N Main St, Rm 204, Concord, NH 03301-4989 
       Physical Location - State House Annex, 3rd Floor, Rm 317, 25 Capitol St, Concord, NH 
 
                                                                                              Form FLLC-3  (9/2015)