Limited Liability Company Name: _____________________________________________________________
Entity Number: ____________________ State of Formation: ____
This Limited Liability Company declares that it no longer conducts business in Utah and withdraws its
registration to do business.
This Limited Liability Company revokes the authority of its registered agent to accept service on its behalf in
Utah and provides this address to which service of process may be made (16-17-301).
__________________________________________________________________________________________
Street Address City State Zip
Pursuant to the provisions of the Utah
Limited Liability Company Act, the undersigned Limited Liability
Company adopts this Statement of Withdrawal (48-3a-911).
Under penalties of perjury, I declare that this Withdrawal has been examined by me and is, to the best of my
knowledge and belief, true, correct and complete.
By: ________________________________________ Title: ______________________ Date: _____________
Signed by a person authorized by the Limited Liability Company
Additional filing requirements:
If the filer requests a copy of the Withdrawal 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
Withdrawal of Registration of a Foreign Limited Liability Company
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
