CSCL/CD-761 (Rev. 09/21 )

       MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
            CORPORATIONS, SECURITIES & COMMERCIAL LICENSING BUREAU
Date Received                                               (FOR BUREAU USE ONLY)
                             AC1

                             This document is effective on the date filed, unless a
                             subsequent effective date within 90 days after received
                             date is stated in the document.
Name

Address

City                                 State                                    ZIP Code
                                                                                      EFFECTIVE DATE:
       Document will be returned to the name and address you enter above.
            If left blank, document will be returned to the registered office.

                             APPLICATION FOR CERTIFICATE OF WITHDRAWAL
                                     For use by Foreign Limited Liability Companies
                                     (Please read information and instructions on the last page)
                   Pursuant to the provisions of Act 23, Public Acts of 1993, the undersigned execute the following Application:

1. The name of the limited liability company is:

2. The identification number assigned by the Bureau is:

3. It is organized under the laws of

4. The limited liability company is not transacting business or conducting affairs in Michigan.

5. The limited liability company hereby surrenders its authority to transact business or conduct affairs in Michigan.

6. The limited liability company revokes the authority of its resident agent to receive service of process in this state and consents that
service of process in any action, suit, or proceeding based upon any cause of action arising in this state during the time the foreign
limited liability company was authorized to transact business in this state may thereafter be made on the company by service upon the
administrator.
7. The address to which the administrator is to mail a copy of any process against this limited liability company is:

     (Name)

            (Street Address)                      (City)                              (State)                        (ZIP Code)

                         Signed this       day of                                               ,

                         By
                                                            (Signature)

                             (Type or Print Name)                                     (Type or Print Title)

CSCL/CD-761 (Rev. 09/21) 
  
Preparer's Name

Business telephone number               )(

                                            INFORMATION AND INSTRUCTIONS
  1. The application for Certificate of Withdrawal cannot be filed until this form, or a comparable document is submitted.

  2. Submit one original of this document.  Upon filing, the document will be added to the records of the Corporations, Securities &
     Commercial Licensing Bureau.  The original will be returned to your registered office address unless you enter a different address in
     the box on the front of this document.

     Since this document will be maintained on electronic format, it is important that the filing be legible.  Documents with poor black and
     white contrast, or otherwise illegible, will be rejected.

  3. This application is to be used pursuant to section 1006 of Act 23, P.A. of 1993, for the purpose of withdrawing a limited liability
     company's Certificate of Authority to Transact Business in Michigan.  Upon filing of this Application the limited liability company
     surrenders its Certificate of Authority to Transact Business in this state.

  4. Item 2 - Enter the identification number assigned by the Bureau.  If this number is unknown, leave it blank.

  5. This Application must be signed by a person with authority to sign as provided in the laws of the jurisdiction of its organization.

  6. The limited liability company must request a tax clearance within 60 days after submitting this certificate from the Michigan
     Department of Treasury, Tax Clearance Division, Lansing, MI  48922, (517) 636-5260.

  7. NONREFUNDABLE FEE:  Make remittance payable to the State of Michigan.  Include limited liability company name and
       identification number on check or money order.........................................................................................................................$10.00
  Veterans: Pursuant to MCL 450.5101(9)(10), if a majority of the membership interests in the foreign limited liability company 
  responsible for paying the fee are held by 1 or more veterans who served in the United States Armed Forces, (including the 
  reserve components) who were discharged or released under conditions other than dishonorable, you may obtain further 
  information regarding a fee waiver at www.michigan.gov/corpveteranfeewaivers.
  Submit with check or money order by mail:                                     To submit in person: 
                                                                                     2407 N Grand River Ave 
      Michigan Department of Licensing and Regulatory Affairs                        Lansing, MI 48906 
      Corporations, Securities & Commercial Licensing Bureau
                                                                                     Telephone:  (517) 241-6470 
      Corporations Division
      P.O. Box 30054                                                            Fees may be paid by check, money order, VISA,MasterCard                                            , 
      Lansing, MI  48909                                                        American Express, or Discover when delivered in person to   
                                                                                our office. 

  COFS (Corporations Online Filing System): 
  This document may be completed and submitted online at www.michigan.gov/corpfileonline.
  Fees may be paid by VISA, MasterCard, American Express, or Discover. 

  Documents that are endorsed filed are available at www.michigan.gov/corpentitysearch.  If the submitted document is not fileable, the notice of refusal to 
  file and document will be available at the Rejected Filings Search website at www.michigan.gov/corprejectedsearch. 

  LARA is an equal opportunity employer/program.  Auxiliary aids, services and other reasonable accommodations are available upon request to individuals
  with disabilities.

Optional expedited service.
Expedited review and filing, if fileable, is available for all documents for profit corporations, limited
liability companies, limited partnerships and nonprofit corporations.

The nonrefundable expedited service fee is in addition to the regular fees applicable to the specific
document.

Please complete a separate CSCL/CD-272 form for expedited service for each document 
submitted in person or by mail. 

24-hour service - $50 for formation documents and applications for certificate of authority.

24-hour service - $100 for any document concerning an existing entity.

Same day service
           Same day - $100 for formation documents and applications for certificate of
           authority.
           Same day - $200 for any document concerning an existing entity.
      Review completed on day of receipt.  Document and request for same day expedited
      service must be received by 1 p.m. EST OR EDT.

           Two hour - $500
      Review completed within two hours on day of receipt.  Document and request for two hour
      expedited service must be received by 3 p.m. EST OR EDT.

           One hour - $1000
      Review completed within one hour on day of receipt.  Document and request for 1 hour
      expedited service must be received by 4 p.m. EST OR EDT.

Documents submitted by mail are delivered to a remote location for receipts processing and are
then forwarded to the Corporations Division for review.  Day of receipt for mailed expedited service
requests is the day the Corporations Division receives the request.

Rev. 09/21