Statement Of Cancellation Of Foreign Qualification {MLLC-12B}

Filing Fee $90.00 LIMITED LIABILITY COMPANY STATE OF MAINE STATEMENT OF CANCELLATION OF FOREIGN QUALIFICATION (for a Foreign LLC) _____________________ Deputy Secretary of State A True Copy When Attested By Signature ______________________________________ (Name of Limited Liability Company in Jurisdiction of Organization) _____________________ Deputy Secretary of State Pursuant to 31 MRSA §1628, the undersigned foreign limited liability company hereby cancels its statement of qualification in the State of Maine and states the following: FIRST: If different, the fictitious name under which the limited liability company adopted to do business in the State of Maine pursuant to §1510-1.B is: _______________________________________________________________________________________________ SECOND: Its jurisdiction of organization is _____________________________ (state or country) and the date of organization is _____________________________. THIRD: The date on which the foreign limited liability company was qualified to conduct activities in the State of Maine:________________________________. The foreign limited liability company will no longer conduct business in the State of Maine and it relinquishes its authority to conduct business and is cancelling its statement of foreign qualification. FOURTH: FIFTH: If the foreign limited liability company is not maintaining the registered agent in the State of Maine, the mailing address to which service of process may be mailed pursuant to §1662 is: ____________________________________________________________________ (Principal office address) ____________________________________________________________________ (Principal office address) SIXTH: The street and mailing address of the foreign limited liability company's principal office is: _______________________________________________________________________________________________ (street, city, state and zip code) Form No. MLLC-12B (1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com SEVENTH: The foreign limited liability company acknowledges that any assumed name(s) if adopted pursuant to §1510-1.A, will be withdrawn upon the effective date of this statement of cancellation. DATED __________________________ *Authorized person(s) ________________________________________________ (authorized signature) _______________________________________________ (type or print name and capacity) *Pursuant to 31 MRSA §1676.1B, this statement MUST be signed by a person authorized by the limited liability company. The execution of this certificate constitutes an oath or affirmation under the penalties of false swearing under 17-A MRSA §453. Please remit your payment made payable to the Maine Secretary of State. Submit completed form to: Secretary of State Division of Corporations, UCC and Commissions 101 State House Station Augusta, ME 04333-0101 Telephone Inquiries: (207) 624-7752 Email Inquiries: CEC.Corporations@Maine.gov Form No. MLLC-12B (2 of 2) 7/1/2011 American LegalNet, Inc. www.FormsWorkFlow.com Filer Contact Cover Letter To: Department of the Secretary of State Division of Corporations, UCC and Commissions 101 State House Station Augusta, ME 04333-0101 Tel. (207) 624-7752 Name of Entity (s): _______________________________________________________________________ _______________________________________________________________________ List type of filing(s) enclosed (i.e. Articles of Incorporation, Articles of Merger, Articles of Amendment, Certificate of Correction, etc.) Attach additional pages as needed. ________________________________________________________________________ ________________________________________________________________________ Special handling request(s): (check all that apply) Hold for pick up Expedited filing - 24 hour service ($50 additional filing fee per entity, per service) Expedited filing - Immediate service ($100 additional filing fee per entity, per service) Total filing fee(s) enclosed: $ ________________ Contact Information ­ questions regarding the above filing(s), please call or email: (failure to provide a contact name and telephone number or email address will result in the return of the erroneous filing (s) by the Secretary of State's office) ___________________________________ (Name of contact person) ___________________________________ (Daytime telephone number) ____________________________________________________ (Email address) The enclosed filing(s) and fee(s) are submitted for filing. Please return the attested copy to the following address: ______________________________________________________________________________ (Name of attested recipient) _____________________________________________________________________________________________ (Firm or Company) _____________________________________________________________________________________________ (Mailing Address) _____________________________________________________________________________________________ (City, State & Zip) American LegalNet, Inc. www.FormsWorkFlow.com