COVER LETTER 
                                                         
TO: Registration Section 
    Division of Corporations 
     
SUBJECT:                                                                                               
                                       Name of Limited Liability Company 
                                                         
DOCUMENT NUMBER:                                                                                       
 
The enclosed Resignation of Registered Agent for a Limited Liability Company and fee are submitted 
for filing. 
 
Please return all correspondence concerning this matter to the following: 
 
                        Name of Person 
 
                         Name of 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 
 
Enclosed is a check made payable to the Florida Department of State for $85.00 for an active limited 
liability company or $25.00 for an administratively dissolved, voluntarily dissolved or withdrawn 
limited liability company. 
 
    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 
                            
INHS17 (2/14)  
 

   STATEMENT OF RESIGNATION OF REGISTERED AGENT  
                      FOR A LIMITED LIABILITY COMPANY 
 
Pursuant to the provisions of section 605.0115, Florida Statutes, the undersigned, 
 
                                                                                                                        , hereby resigns as  
                      Name of Registered Agent  
 
Registered Agent for                                                                                                                           
 
                                                                                                                                              , 
                                     Name of Limited Liability Company 
 
            Document Number, if known 
 
A copy of this resignation was mailed to the above listed limited liability company at its last known address. 
 
The agency is terminated and the office discontinued on the 31st day after the date on which this statement is filed. 
 
                                             Signature of Resigning Agent 
 
If signing on behalf of an entity: 
 
                                          Typed or Printed Name 
 
                                                   Capacity 
 
                                       FILING FEES:  
                                       $ 85.00      Active limited liability company  
                                       $ 25.00      Administratively dissolved/ voluntarily dissolved/  
                                              withdrawn limited liability company 
 
                       Make checks payable to Florida Department of State and mail to: 
                                          Division of Corporations 
                                                 P.O. Box 6327 
                                              Tallahassee, FL  32314 
 
INHS17 (2/14)