S                                                                  (225) 925-4704  
                                         TATE OF LOUISIANA                                                 Commercial Division    
                                        SECRETARY OF STATE                                                   
    R. Kyle Ardoin                                                                                         Fax Numbers 
SECRETARY OF STATE                                                                                         (225) 932-5314 Corporations 
                                                                                                           (225) 932-5317 Legal Services 
                                                                                                           (225) 932-5318 UCC 
                                                                                                                                               
                            TRANSMITTAL INFORMATION 
                                  For All Business Filings

 Please indicate below the level of service requested, payment and contact information

     Routine         Expedite $30                         Priority Expedite $50
                     24 hour processing                  2-4 hour processing

     Check or Money Order Enclosed

*Do not put credit card information on this form. You may save payment information in your geauxBIZ profile under master account.

Business Name (List  exactly  as it appears in documents)

Name of person filing document (evidence of filing will be mailed to this person, at address below)

Address

City                                     State                                                     Zip Code

Daytime phone number                    Fax number                                                 Email address

NOTE:  Louisiana Law requires all Louisiana notaries to print or type their name and notary or 
       bar roll number on the document.

                     Mailing Address:  P. O. Box 94125, Baton Rouge, LA * 70804-9125      
                     Office Location: 8585 Archives Ave.,  Baton Rouge, LA * 70809          
                                  Web Site Address:   www.sos.la.gov

 SS984  Rev. 06/18

R. Kyle Ardoin                          APPLICATION FOR WITHDRAWAL OF A FOREIGN CORPORATION/
Secretary of State                      LIMITED LIABILITY COMPANY FROM THE STATE OF LOUISIANA
                                                              (R.S. 12:312 & 12:1351)

                     Enclose $125 (Corporation) filing fee       Return  to:   Commercial Division
                     $150 (Limited Liability Company) filing fee               P.O. Box 94125
                     Make remittance payable to                                Baton Rouge, LA 70804-9125 
                                           Secretary of State                  (225) 925-4704
                                         Do Not Send Cash                      www.sos.la.gov

STATE OF

PARISH/COUNTY OF

                                          Company Name

organized under the laws of the state/country of                   is no longer transacting business in 

the State of Louisiana, effective                                surrenders its authority to transact business in the 

state of Louisiana; revokes the authority of its registered agent to accept service of process, and consents that 

service of  process in any action or proceeding based on any cause of action arising out of or resulting from or 

connected with  any business transacted by it in this State during the time the company was authorized to transact 

business in this State, be made on the company by service thereof on the Secretary of State, or on a person in his 

office designated  to receive service of process; such service, if made on the Secretary of State.

                                        Officer/Manager or Member                                 Date

Sworn to and subscribed before me, the undersigned Notary Public, on this date:

                                                 Notary

SS338 Rev. 05/18                                                                     (see instructions on back)

                                      INSTRUCTIONS

1. A foreign corporation or limited liability company authorized to transact business in this state may 
   withdraw from this state upon procuring from the Secretary of State a Certificate of Withdrawal.

2. In order to obtain a Certificate of Withdrawal, this application must be executed in duplicate by any 
   officer for a corporation, or by a manager, if management of the limited liability company is vested 
   in one or more managers, or a member, if management is reserved to the members, for a limited 
   liability company.  The application must be acknowledged by the signing party before a notary 
   public.  (If the withdrawal is for a corporation which is in the hands of a receiver or a trustee, this 
   form shall be executed on behalf of the corporation by such receiver or trustee and     acknowledged 
   by him.)

3. A Certificate of Withdrawal shall be issued when all fees, charges, taxes, unemployment 
   compensation, distributions and interest have been paid as required by law and evidenced by 
   certificates of the Collector of Revenue and the Administrator of the Division of Employment 
   Security of the Department of Labor.  (The Secretary of State’s Office requests these  ertificatesc  
   from the above offices.)

4. Upon the issuance of a Certificate of Withdrawal, the authority of the company to transact business 
   in Louisiana shall cease.