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 
                                                                                                                     www.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: 
  
                                                                                                                                                                             .                  
                                                                        Capacity of signer (Check appropriate box):  
 X 
                                    (Signature)                                     Member 
 
                                                                                    Manager 
                         (Type or Print Name of Signer) 
                                                                                    Authorized Person 
 DOS-1379-f (Rev. 03/17)                                                                                              Page 1 of 2

                         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 www.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. 03/17)                                                                                               Page 2 of 2