GP 
                                  (For Office Use Only) 

                                  COVER LETTER 

TO: Reinstatement Section 
    Division of Corporations 

SUBJECT:  
                                           (Name of Partnership) 

DOCUMENT NUMBER:    

The enclosed Statement of Dissociation for Partnership 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) 

For further information concerning this matter, please call: 

                                             at (                ) 
               (Name of Person)                     (Area Code & Daytime Telephone Number) 

    Mailing Address:                                             Street Address: 
    Reinstatement Section                                        Reinstatement 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 

CR2E071 (9/15) 

        STATEMENT OF DISSOCIATION FOR PARTNERSHIP 

Pursuant to section 620.8704, Florida Statutes, I hereby submit the following statement of dissociation: 

FIRST:  The name of the partnership is: 

SECOND:  (CHECK ONE) 
☐ The partnership was registered with the Florida Department of State on

  and assigned registration number  GP                                     . 

☐ The partnership has not registered with the Florida Department of State.

THIRD:  The purpose of this document is to state that 

                                                              has dissociated as a partner from
                     (Partner’s Name) 

                                                                               . 
                        (Partnership Name) 

FOURTH:  Effective date, if other than the date of filing:                    . 
(Effective date cannot be prior to the date of filing nor more than 90 days after the date of filing.) 

NOTE:  If the date inserted in this block does not meet the applicable statutory filing requirements, 
this date will not be listed as the document’s effective date on the Department of State’s records.  

The execution of this statement in compliance with s. 620.8105(6) constitutes an affirmation under the 
penalties of perjury that the facts stated herein are true. 

I am aware that any false information submitted in a document to the Department of State constitutes 
a third degree felony as provided for in s. 817.155, F.S 

Signed this _____ day of ____________________________,  _______. 

                                           (Signature) 

                       (Typed or printed name of person signing above) 

                       Filing Fee:           $25.00 
                     Certified copy:                  $52.50 (optional) 
                     Certificate of Status:           $  8.75 (optional) 

        Make checks payable to Florida Department of State and mail to: 
        Division of Corporations P.O. Box 6327 Tallahassee, FL  32314