Arkansas Secretary                                                     of State         
                                                                      1401 W.Capitol,     Suite 250,     Little Rock, AR 72201
                                                                        501-682-3409 • www.sos.arkansas.gov
                  John Thurston 

                  APPLICATION FOR CANCELLATION 
                  BY FOREIGN LIMITED LIABILITY COMPANY 
                                                   (PLEASE TYPE OR PRINT CLEARLY IN INK) 

The undersigned, pursuant to Act 1041 of 2021, sets forth the following:

1. Foreign Limited Liability Company Name: ___________________________________________________________

_____________________________________________________________________________________________

2. State of Organization: ___________________________________________________________________________

3. The Foreign Limited Liability Company is not transacting business in this State and hereby surrenders its authority to
do so.

4. The Foreign Limited Liability Company revokes the authority of its registered agent to accept service on its behalf
and appoints the Secretary of State as its agent for service of process in any action, suit or proceeding based on a
cause of action arising during the time it was authorized to transact business in this State.  The Arkansas Secretary
of State shall hereafter be the authorizing recipient of service for valid service of process on this Foreign Limited
Liability Company.

5. The Foreign Limited Liability Company’s mailing address for any service of process pursuant to paragraph four is:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

I affirm that I am the individual authorized to sign on behalf of the aforementioned entity to be formed and that, under       
penalty of perjury, the information stated in this record is accurate.

Executed this ____________________ day  of _____________________, ____________________________. 

                                                                      ____________________________________________________________
                                                                                                Signature

                                                                      ____________________________________________________________
                                                                                                Name

                                                                      ____________________________________________________________
                                                                                                Title

Fee: $50.00 payable to Arkansas Secretary of State                                                              FL-04 Rev. 8/21