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                                                                                          FILE #
Form                                                    Illinois 
                                                                                                             This space for use by Secretary of State.
July 2017LLC-45.40                             Limited Liability Company Act
Secretary of State  
Department of Business    Services             Application for Withdrawal
Limited Liability Division
501 S. Second St., Rm. 351                     SUBMIT IN DUPLICATE
Springfield, IL  62756                         Type or print clearly.
217-524-8008
www.ilsos.gov
Payment  may  be  made  by  check              Filing Fee:      $5
payable  to  Secretary  of  State.  If         Approved:
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. December 2017 — 1 — LLC 10.9