COVER LETTER 
                                                 
TO: Registration Section 
    Division of Corporations 
 
SUBJECT:                                                                                
                               Name of Limited Liability Company 
                                                 
Dear Sir or Madam: 
 
The enclosed Statement of Denial and fee(s) are submitted for filing. 
 
Please return all correspondence concerning this matter to the following: 
 
                          Name of Person 
 
                          Firm/Company 
 
                   Address 
 
               City/State and Zip Code 
 
    E-mail address: (to be used for future annual report notification) 
 
For further information concerning this matter, please call: 
 
                                                 at (        )                          
               Name of Person                          Area Code         Daytime Telephone Number 
 
    Mailing Address:                                         Street Address: 
    Registration Section                                     Registration Section 
    Division of Corporations                                 Division of Corporations 
    P.O. Box 6327                                            The Centre of Tallahassee 
    Tallahassee, FL 32314                                    2415 N. Monroe Street, Suite 810 
                                                             Tallahassee, FL 32303 
                
CR2E139 (2/14) 

                                        STATEMENT OF DENIAL 

Pursuant to section 605.0303, Florida Statutes, I hereby submit the following statement of denial: 

FIRST:  The name of the limited liability company is:                                                
 
SECOND:  The document number of this limited liability company is:                                   
 
THIRD:  The statement of authority to which this statement of denial pertains is:                    
 
and this grant of authority is denied.  
 
         Signature of person submitting denial                  Typed or printed name of signature 
 
                                        Filing Fee:     $25.00 
                                        Certified Copy:  $30.00 (optional) 

CR2E139 (2/14)