This form cannot be hand written.
            State of Utah 
            Department of Commerce 
            Division of Corporations & Commercial Code                                                                                    Print
            Withdrawal of Registration of a Foreign Limited Liability Company                                                             Clear Form

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: ________________________________________Sign here after the form is printedTitle: ______________________ 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. 

Mailing/Faxing Information: www.corporations.utah.gov/contactus.html                  Division's Website:             www.corporations.utah.gov

04/16