PENNSYLVANIA DEPARTMENT OF STATE 
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS       
                                                                                                               
      Return document by mail to:                                                            
                                                                                               Statement of Withdrawal 
                                                                                             from Registered Limited Liability Partnership 
 Name                                                                                          DSCB:15-8205    (rev. 7/2015) 
                                                                                                                                                                                                                    
 Address                                                                                                       
  
 City                                            State                             Zip Code    *8205*
                                                                                                                                     
                                                                                                         8205 
      Return document by email to: _________________________________ 
 
      Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/.  
 
Fee:  $70 
 
         In compliance with the requirements of 15 Pa.C.S. § 8205(c) (relating to statement of withdrawal), the 
undersigned partner of a registered limited liability partnership, desiring to evidence the partner's withdrawal from a 
registered limited liability partnership, hereby certifies that: 
 
      1.  The name of the registered limited liability partnership is: 
       
      2.  The name of the person withdrawing is:   
       
                                                   IN TESTIMONY WHEREOF, the undersigned 
                                                   person has caused this Statement of Withdrawal to be 
                                                   executed this 
                                                    
                                                                day of                                     ,                     . 
                                                    
                                                                                               Name of Person 
                                                                                                
                                                                                               Signature 
 
                                                                                               Title 

DSCB:15-8205 - Instructions 
                                                          
                                     Pennsylvania Department of State 
                            Bureau of Corporations and Charitable Organizations 
                                           P.O. Box 8722 
                                           Harrisburg, PA  17105-8722 
                                           (717) 787-1057 
                                           web site: www.dos.pa.gov/corps 
                                                          
Instructions for Completion of Form: 
 
A.  Typewritten is preferred.  If handwritten, the form shall be legible and completed in black or blue-black ink in order 
 to permit reproduction.  The nonrefundable filing fee for this form is $70 made payable to the Department of State. 
 Checks must contain a commercially pre-printed name and address. 
 
 Enter the name and mailing address to which any correspondence regarding this filing should be sent.  This field must 
 be completed for the Bureau to return the filing. If the filing is to be returned by email, an email address must be 
 provided. An email will be sent to address provided, containing a link and instructions on how a copy of the filed 
 document or correspondence may be downloaded. Any email or mailing addresses provided on this form will become 
 part of the filed document and therefore public record. 
 
B.   This form shall be executed by the person identified in the form as withdrawing as a partner from the partnership. If 
 this form is executed by the personal representative of the withdrawing partner, the execution portion of the form 
 should be modified accordingly. 
 
C.  Under 15 Pa.C.S. § 8205(d), the person withdrawing shall send a copy of the filed statement of withdrawal to the 
 registered limited liability partnership. 
 
D.  This form and all accompanying documents shall be mailed to the address stated above.