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
1. Limited Liability Company name: ____________________________________________________________________
______________________________________________________________________________________________
2. State or country of organization: ___________________________________________________________________
3. Street address to which a copy of any process against the company served on the Secretary of State may be mailed:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. The company is not transacting business in Illinois.
5. The company surrenders its admission to transact business in Illinois.
6. The company revokes the authority of its registered agent in Illinois and consents that service of process may hereafter be
made on the company by service thereof upon the Secretary of State.
7. The undersigned affirms, under penalties of perjury, having authority to sign hereto, that this application for withdrawal is
to the best of my knowledge and belief, true, correct and complete.
Dated _________________________________, _______________
Month & Day Year
______________________________________________________________
Signature
______________________________________________________________
Name and Title (type or print)
______________________________________________________________
If applicant is signing for a company or other entity,
state name of company or entity.
Form LLC-45.40
July 2017
Illinois
Limited Liability Company Act
Application for Withdrawal
SUBMIT IN DUPLICATE
Type or print clearly.
F
iling Fee: $5
Approved:
Payment may be made by check
payable to Secretary of State. If
check is returned for any reason this
f
iling will be void.
Printed by authority of the State of Illinois. December 2017 — 1 — LLC 10.9
This space for use by Secretary of State.
F
ILE #
RETURN TO: (Please type or print clearly.)
___________________________________________________________
Name
___________________________________________________________
Street
___________________________________________________________
City, State, ZIP Code
