1. Li
m
i
ted Li
abi
l
i
ty
Com
pany
nam
e:
_________
___________________________________________________________
2.
The c
apti
on of the S
tatem
ent of
A
uthor
i
ty
that i
s
deni
ed:
__________________________________________________
____
_______________________________
_______________________________
____________________________
____
_______________________________
________________________________
___________________________
3. Filed or
ef
fective date of or
iginal S
tatem
ent of
A
uthor
ity: ________________________
____, ____________________
4.
The under
signed declar
es, under
penalties of per
jur
y
, having author
ity to sign her
eto, that this S
tatement of
Denial is to the best of my knowledge and belief, tr
ue, cor
r
ect and complete.
Date: _______
_____________________ ____
________________
___
_______________________________
________________
___________________
_______________________________
___________________
_______________________________
Form LLC-13.20
July 2017
Illinois
Limited Liability Company Act
Statement of Denial
Printed by authority of the State of Illinois. July 2017 — 1 — LLC 49
SUBMIT IN DUPLICATE
Type or print clearly.
Filing Fee: $10
Approved:
S
ecretary of State
Department of Business Services
Limited Liability Division
501 S. Second St., Rm. 351
Springfield, IL 62756
2
17-524-8008
www.cyberdriveillinois.com
Payment may be made by check
payable to Secretary of State. If check
is returned for any reason this filing
w
ill be void.
This space for use by Secretary of State.
F
ILE #
Month, Day Year
If applicant is signing for a company or other entity, state name of company or entity.
Month, Day Year
,
Name and Title (type or print)
Signature
