Limited Liability Company Name: _____________________________________________________________
Entity Number: _______________________
The dissolution of above named limited liability company will become effective:
upon filing with the Division of Corporations and Commercial Code.
on the future effective date of (MM-DD-YYYY) _____________________________.
The dissolution shall be signed by a person authorized by the LLC.
If the LLC has no member(s) or manager(s), the dissolution shall be signed by:
Person winding up the LLC’s activities and affairs under Subsection 48-3a-703(3).
Under penalties of perjury, I declare that this Statement of Dissolution has been examined by me and is, to the
best of my knowledge and belief, true, correct and complete.
By: _______________________________________
Name: _________________________________________
Date: ________________
Additional filing requirements:
If the filer requests a copy of the Statement of Dissolution an additional exact copy of the filed document along
with a return-addressed envelope with adequate first-class postage must also be submitted.
Under GRAMA {63G-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes,
you may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity.
State of Utah
Department of Commerce
Division of Corporations & Commercial Code
Statement of Dissolution
This form cannot be hand written.
Sign here after the form is printed
Mailing/Faxing Information:
www.corporations.utah.gov/contactus.html
www.corporations.utah.gov
