Cancellation Of Certificate Of Authority Following Administrative Revocation {SS-4254}

For Office Use Only Corporate Filings 312 Rosa L. Parks Ave. 6th Floor, William R. Snodgrass Tower Nashville, TN 37243 (LIMITED LIABILITY COMPANY) CANCELLATION OF CERTIFICATE OF AUTHORITY FOLLOWING ADMINISTRATIVE REVOCATION Pursuant to the provisions of §48-246-505 of the Tennessee Limited Liability Company Act or §48-249-912 of the Tennessee Revised Limited Liability Company Act, the undersigned Limited Liability Company hereby applies for a Certificate of Cancellation of Certificate of Authority following administrative revocation from the State of Tennessee, and for that purpose sets forth: 1. The name of the Limited Liability Company is: If different, the name under which the certificate of authority was obtained is: 2. The date of revocation month, day, year . 3. The state or country under whose law it is formed is: _________________________________________________ 4. The Limited Liability Company is not transacting business in the State of Tennessee and surrenders its authority to transact business in this state. 5. Please mark the applicable statement: (a) The Limited Liability Company continues its registered office in the State of Tennessee. (b) The Limited Liability Company hereby 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. 6. The mailing address (including zip code) to which the Secretary of State may mail a copy of any process served on him is: 7. The undersigned Limited Liability Company makes the commitment to notify the Secretary of State in the future of any change in its mailing address. Signature Date Name of the Limited Liability Company Signer's Capacity Signature Name (typed or printed) SS-4254 (Rev. 01/06) Filing Fee: $100 RDA 2458 American LegalNet, Inc. www.FormsWorkFlow.com