Wyoming Secretary of State 
                                      Herschler Building East, Suite 101
                                                                                       For Office Use Only 
                                             122 W 25th Street 
                                      Cheyenne, WY 82002-0020 
                                             Ph. 307.777.7311 
                                             Email: Business@wyo.gov   

                                             Foreign Limited Liability Company 
                                      Application for Certificate of Withdrawal 

Pursuant to W.S. 17-16-1520, the undersigned limited  liability company hereby applies for a Certificate of 
Withdrawal from the state of Wyoming. 

1. Name of the limited liability company:

2. Organized under the laws of:
                                             (State or country) 

3. It is no longer transacting business in  the  state  of Wyoming; and it  hereby surrenders its authority to  transact
business in the state of Wyoming. 

4. It 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 proceeding based on a cause of action arising during the time it was authorized 
to transact business in this state. 

5. Mailing address to which the Secretary of State may mail a copy of any process served on him under Item 4:

6. It will notify the Secretary of State in the future of any change in its mailing address.

Signature: ___________________________________________                            Date: 
(May be executed by a member, manager, or other authorized individual as set                      (mm/dd/yyyy) 
 forth in the operating agreement.) 

Print Name:                                                     Contact Person: 

Title:                                                          Daytime Phone Number: 

                                                                Email:  

                                                                (Email provided will receive filing evidence) 
                                                                *May list multiple email addresses

Checklist 
       Filing Fee: $50.00   Make check or money order payable to Wyoming Secretary of State.
       Please submit one originally signed document. 
       The business entity is active and in good standing with this office.
       Typical processing time is 3-5 business days following the date of receipt in our office.  
       Please review form prior to submitting to the Secretary of State to ensure all areas have been completed to avoid 
       a delay in the processing of your documents. 

FLLC-CertificateWithdrawal          – RevisedAugust 201 9