ArkansasSecretaryofState                                                       
                                                  1401W.Capitol,                     Suite 250, LittleRock , 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 1003 of 1993 and Arkansas Code Annotated § 4-32-1006, 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 understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a 
Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days. 

Executed this ____________________ day  of _____________________, ____________________________. 

__________________________________________________  ____________________________________________ 
Authorizing Officer and Title (Type or Print)     Authorized Signature 

NO FEE                                                                                           FL-04 Rev. 11/18