New York State 
                                                                         Department of State 
                                                               DIVISION OF CORPORATIONS, 
                                                                         STATE RECORDS AND  
                                                               UNIFORM COMMERCIAL CODE 
                                                                         One Commerce Plaza 
                                                                         99 Washington Ave. 
                                                                         Albany, NY 12231-0001 
                                                                         https://dos.ny.gov                                         
DOCUMENT AND CERTIFICATE COVER SHEET 

Contact Information 
 
Name:   ______________________________________________________________________________ 
 
Mailing Address:_______________________________________________________________________ 
                   
              _____________________________________________________________________________ 
 
Email Address: ______________________________________________________________________ 
 
Phone Number:  ______________________________________________________________________ 
 
Request for Filing of Document 
 
Exact Name of Entity: __________________________________________________________ 
____________________________________________________________ 
 
Document Type:_______________________________________________________________  
                                   (i.e., Certificate of Incorporation, Articles of Organization, Certificate of Amendment, etc.): 
 
Request for Copies or Certificates of Status (Check the appropriate box) 
 
Exact Name of Entity: __________________________________________________________ 

□ Certified Copies of all Documents on File ($10 per document) 

□ Plain Copies of all Documents on File ($5 per document) 

□Certified Copy of _____________________________________________________ ($10 per document) 
                               (specify document) 

□ Plain Copy of ________________________________________________________ ($5 per document) 
                               (specify document) 

□ Certificate of Status - Long Form ($25 per document) 

□ Certificate of Status - Short Form ($25 per document)   
 
Method of Delivery of Filing Receipt or Other Document  

All documents will be returned to the email address listed above with the exception of certified and 
uncertified copies filed before July 1990. 

DOS-2183-f (04/22) 

                                                                                                              New York State 
                                                                                                              Department of State 
                                                                                                              DIVISION OF CORPORATIONS, 
                                                                                                              STATE RECORDS AND  
                                                                                                              UNIFORM COMMERCIAL CODE 
                                                                                                              One Commerce Plaza 
                                                                                                              99 Washington Ave. 
                                                                                                              Albany, NY 12231-0001 
                                                                                                              https:/dos.ny.gov 

         CERTIFICATE OF SURRENDER OF AUTHORITY  

                                             OF 
 
                           (Insert Name of Foreign Limited Liability Company) 
                           Under Section 806 of the Limited Liability Company Law 

 FIRST: The name of the foreign limited liability company as it appears on the index of names in the 
 Department of State is:   
                                                                                                                                                                                   
                                                                                                                                                                                         . 
 If applicable: the fictitious name the foreign limited liability company has agreed to use in New York State is: 
  
                                                                                                                                                                                   . 
 SECOND: The jurisdiction of organization of the foreign limited liability company is: 
  
                                                                                                            . 
 THIRD: The date on which its application for authority to do business in this state was filed with the 
 Department of State is: 

                                                                                                          . 
 FOURTH: The foreign limited liability company surrenders its authority to do business in New York State. 

 FIFTH: The foreign limited liability company hereby revokes the authority of its registered agent, if any, 
 previously designated and it hereby consents that process against it in any action or special proceeding based 
 upon any liability or obligation incurred by it within this state before the filing of the certificate of surrender 
 of authority may be served on the Secretary of State in the manner set forth in Article 3 of the Limited 
 Liability Company Law. 

 SIXTH: The address within or without this state to which the Secretary of State shall mail a copy of any 
 process against the foreign limited liability company served upon him or her is: 
  
                                                                                                                                                                             .  
  
 DOS-1379-f  (Rev. 12/22)                                                                                       Page 1 of 3 

 SEVENTH: (Optional) 
  
       The email address to which the Secretary of State shall email a notice of the fact that process   
       against the foreign limited liability company has been served electronically upon the Secretary of 
       State is: 

                                                                                                                  . 
      The email address to which the Secretary of State shall email a notice of the fact that process   
   
       against the foreign limited liability company has been served electronically upon the Secretary of 
       State is changed to read as follows: 

                                                                                                                  . 
  
                                                           Capacity of signer (Check appropriate box):  
 X 
                                     (Signature)                       Member 
 
                                                                       Manager 
                          (Type or Print Name of Signer) 
                                                                       Authorized Person 

 DOS-1379-f  (Rev. 12/22)                                                                                   Page 2 of 3 

                          CERTIFICATE OF SURRENDER OF AUTHORITY 
                                                OF 
 
                                   (Insert Name of Foreign Limited Liability Company) 
 
                                   Under Section 806 of the Limited Liability Company Law 
 
     Filer’s Name and Mailing Address: 

         Name: 

         Company, if Applicable: 

         Mailing Address: 

         City, State and Zip Code: 

 NOTES:  
 1. The name of the foreign limited liability company and the date of filing of the application for authority must exactly match the 
     records of the Department of State.  This information should be verified on the Department of State’s website at  
     https://dos.ny.gov. 
 2. This form was prepared by the New York State Department of State for filing a certificate of surrender of authority for a foreign 
     limited liability company. It does not contain all optional provisions under the law. You are not required to use this form. You  
     may draft your own form or use forms available at legal supply stores.  
 3. The Department of State recommends that legal documents be prepared under the guidance of an attorney.  
 4. The certificate must be submitted with a $60 filing fee made payable to the Department of State. 
   
 (For office use only) 

 DOS-1379-f  (Rev. 12/22)                                                                                                Page 3 of 3