Fill and Sign the Additional Assistance in Examinations and Alternative Examination Arrangements Supporting Medical Documentation Additional Form

Print State of New Hampshire Reset Filing fee: $35.00 Use black print or type. Form FLLC-3 RSA 304-C:179 APPLICATION FOR CERTIFICATE OF CANCELLATION OF REGISTRATION OF FOREIGN LIMITED LIABILITY COMPANY PURSUANT TO THE PROVISIONS of Chapter 304-C, Section 179 of the New Hampshire Revised Statutes Annotated, the undersigned hereby applies for a certificate of cancellation of registration, and for that purpose submits the following statement: FIRST: The name of the limited liability company is . SECOND: It is formed under the laws of . THIRD: It is not doing business in New Hampshire. FOURTH: It hereby surrenders its certificate of registration to transact business in New Hampshire. FIFTH: It revokes the authority of its registered agent for 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 it was authorized to do business in this state may thereafter be made on it by service thereof upon the secretary of state. SIXTH: The mailing address to which a person may mail a copy of any process against the limited liability company that may be served on him is . SEVENTH: Limited liability company must be in good standing as evidenced by the filing of all annual report(s) due. EIGHTH: A statement is attached from the New Hampshire Department of Revenue Administration that all taxes due from or accrued by the limited liability company through the date of the application for a certificate of cancellation of registration have been either assessed and paid or adequately provided for in a manner acceptable to the New Hampshire Department of Revenue Administration. Yes Page 1 of 2 Form FLLC-3 Page 1 APPLICATION FOR CERTIFICATE OF CANCELLATION OF REGISTRATION Form FLLC-3 (Cont.) *Signature: Print or type name: Title: Date signed: * Shall be executed on behalf of the foreign limited liability company by a person with authority to do so under the laws of the state or other jurisdiction of its formation, or, if the foreign limited liability company is in the hands of a receiver, executor, or other court appointed fiduciary, trustee, or other fiduciary, it must be signed by that fiduciary. DISCLAIMER: All documents filed with the Corporation Division become public records and will be available for public inspection in either tangible or electronic form. SECRETARY OF STATE’S CANCELLATION FILING REQUIREMENTS: 1. Obtain original tax certificate from the N.H. Dept. of Revenue Administration. To obtain this tax certificate, Certificate Request Form AU-22 must be completed and submitted to the N.H. Dept. of Revenue Administration. Follow this link to obtain the required form: http://www.revenue.nh.gov/business/certificates.htm 2. Mail completed Form FLLC-3 with original tax certificate from the Dept. of Revenue Administration and $35.00 rd filing fee to: (Physical location: 25 Capitol Street, 3 Floor, Concord, NH 03301) Corporation Division Department of State 107 North Main Street Concord, NH 03301-4989. Page 2 of 2 Form FLLC-3 Page 2 (1/2013)