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kansas secretary of state All information on this form must be
Kansas Limited Liability Company complete and accompanied by the correct
filing fee or the document will not be
KC
Certificate of Cancellation accepted for filing.

GENERAL FILING
File a cancellation online at sos.ks.gov .
INSTRUCTIONS LLCs with series must use Form KC.

o Filing fee The filing fee for this document is $35. There is an additional $20 filing fee for each series listed in the
attachment.

o Payment Please submit payment by check, money order, or credit card. Checks and money orders need to be
made payable to the Secretary of State. Forms received without the appropriate fee will not be accepted
for filing. Please do not send cash.

Visa, MasterCard, Discover, and American Express are accepted. To use a credit card, please provide
the following information:

Credit card number __________________________________________________________________

Billing zip code _____________________________ Expiration date _________________________

NOTICE: There is a $25 service fee for all returned checks.

o Daytime phone and
contact person ___________________________________________________________________________________
o Fax filing available Documents may be fax filed for a processing fee of $20 in addition to the filing fee. Include contact name,
daytime phone number, credit card number, credit card expiration date and billing zip code.
Fax documents and payment information to Business Services, 785-296-4570. Faxed documents will
receive that day’s file date if they are without errors and received prior to 4 PM CST. Fax filing does not
guarantee same day activation or return faxing.
Processed documents will be returned by mail. You may request a file-stamped copy be faxed for an
additional $1 per page.

o No duplicate copies Please do not send duplicate copies of documents. The original is processed, file stamped and returned
by mail to the address provided.

o No email Filings are not accepted by email.

o No filing by phone No documents or reports can be filed with our office by phone.

o Public Information All information filed with our office is available to the public, and much of it may be viewed online without
cost. Please consider this when providing information on our forms.

K.S.A. 17-7675 Please proceed to form.
Inst. Rev. 9/9/20 nw

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kansas secretary of state
Kansas Limited Liability Company Please complete the form, print, sign and mail to the
KC Certificate of Cancellation Kansas Secretary of State with the filing fee. Selecting
'Print' will print the form and 'Reset' will clear the entire
form.

Memorial Hall, 1st Floor (785) 296-4564
120 S.W. 10th Avenue kssos@ks.gov
Topeka, KS 66612-1594 sos.ks.gov 53-02
THIS SPACE FOR OFFICE USE ONLY.

Note: If this certificate is submitted after the close of the limited liability company’s tax year, an annual report and fee
must be submitted with or filed prior to the certificate of cancellation. If the limited liability company has forfeited, it must
reinstate before filing a certificate of cancellation.

1. Business entity ID/file
number:
Not Federal Employer ID
Number (FEIN).

2. Name of limited
liability company:*
Must match name on record
with the Secretary of State.

*If the limited liability company listed above has filed any certificate of designation to form a series, every
series of the limited liability company that has not previously canceled will be canceled with the filing of this
form. Use the attachment provided to list all series to be canceled. If this certificate is submitted after the
close of the series’ tax year, an annual report and fee must be submitted with or filed prior to the certificate of
cancellation. If the series has forfeited, it must reinstate before a certificate of cancellation can be filed.

3. Reason for
cancellation:

4. Effective date: o Upon filing with the o Future effective date: Month Day Year
Kansas Secretary of State (Cannot be later than 90 days
after the date this certificate
is filed.)

5. I/We declare under penalty of perjury pursuant to the laws of the state of Kansas that the foregoing is true and
correct. (The signature of one or more authorized persons is required.)
Signature of Authorized Person

X
Signature of Authorized Person

K.S.A. 17-7675 Please review to ensure completion.
1 / 1 Rev. 9/9/20 nw

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Please
Do NotStaple
                   kansas secretary of state   
            KC     Kansas Limited Liability Company 
            Att.   Certificate of Cancellation
                   Attachment

      This attachment is to be used to list all series that have been formed by the limited liability company listed in Item 2 of 
      the certificate of cancellation. There is a $20 filing fee for each series listed.
      1.   Name and business             Name of Series                                  ID Number
            entity ID/file number of 
            each series:
                                         Name of Series                                  ID Number
            (Name must match name on 
            record with the Secretary of Name of Series                                  ID Number
            State.)

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

                                         Name of Series                                  ID Number

            K.S.A. 17-7675
Att.        Rev. 9/9/20 nw

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