Statement Of Dissociation {LLC-10}

WWW.BUSINESSR EGISTRATIONS.COM FO0RM LLC-1Nonrefundable Filing Fee: $50.00 1/2001 STATE OF HAWAII DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS Business Registration Division  1010 Richards Street Mailing Address: P.O. Box 40, Honolulu, Hawaii 96810 STATEMENT OF DISSOCIATION (Section 428-704, Hawaii Revised Statutes) PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK The undersigned, submitting this Statement, do hereby certify as follows: 1. The name of the limited liability company is: _______________________________________________________________________________________________________________ 2. In compliance with Part VII of the Hawaii Uniform Limited Liability Company Act, the name of the member that has been dissociated from the limited liability company is: _______________________________________________________________________________________________________________ 3. The effective date of dissociation is: _____________________________________________________________________________ We certify, under the penalties set forth in the Hawaii Uniform Limited Liability Company Act, that we have read the abovestatements and that the same are true and correct. Signed this ____________day of ___________________________________, __________ _______________________________________________________ _________________________________________________________ (Type/Print Name & Title) (Type/Print Name & Title)_______________________________________________________ _________________________________________________________ (Signature) (Signature) Instructions : Statement must be typewritten or printed in black ink, and must be legible. The statement must be signed andcertified by the dissociated member or by at least one manager of a manager-managed company or by at least one member of a member-managed company. All signatures must be in black ink. Submit original statement together with the appropriate fee. Line 1. State the full name of the limited liability company. Line 2. State the full name of the dissociated member. Line 3. Give the date (month, day and year) the member was dissociated from the company. Filing Fees: Filing fee ($50.00) is not refundable . Make checks payable to DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS. Dishonored Check ($15 fee plus interest charge). NOTICE: THIS MATERIAL CAN BE MADE AVAILABLE FOR INDIVIDUALS WITH SPECIAL NEEDS. PLEASE CALL THE DIVISION SECRETARY, BUSINESS REGISTRATION DIVISION, DCCA, AT 586-2744, TO SUBMIT YOUR REQUEST.