Fill and Sign the Charles Merwin Ampquottreyampquot Grayson Iii Kentuckygov Form

Kentucky Secretary of State TREY G RAYSON ________________________________________________________________________________________________________ Division of Corporations BUSINESS FILINGS P.O. Box 718 Frankfort, KY 40602 (502) 564-2848 http://www.sos.ky.gov / ________________________________________________________________________\ _____ Certificate of Withdrawal CWA of Assumed Name This certifies that the assumed name of ___________________________________________________________________________________ [Assumed name under which the business is being conducted] has been discontinued by ___________________________________________________________________________________ [Real name - KRS 365.015(1)] which is the “real name” of [YOU MUST CHECK ONE] _____a Domestic General Partnership ______a Foreign General Partnership _____a Domestic Limited Liability Partnership ______a Foreign Limited Liability Partnership _____a Domestic Limited Partnership ______a Foreign Limited Partnership _____a Domestic Business Trust ______a Foreign Business Trust _____a Domestic Corporation ______a Foreign Corporation _____a Domestic Limited Liability Company ______a Foreign Limited Liability Company _____a Joint Venture organized and existing in the state or country of __________________________, and whose address is __________________________________________________________________________ _________. Street address, if any City State Zip Code The certificate of assumed name was filed with the Secretary of State on ________________________. The certificate of withdrawal of assumed name is executed by ____________________________________ _______________________________ Signature Signature ____________________________________ _______________________________ Print or type name and title Print or type name and title ____________________________________ _______________________________ Date Date CWA (06/07) (See attached sheet for instructions) Certificate of Withdrawal of Assumed Name Filing Instructions ASSUMED BUSINESS NAME AND DATE OF FILING The certificate must state the assumed nam e as filed with the Secretary of State. Give the date the certificate of assumed nam e was filed with the Secretary of State. NOTE: A separate certificate must be fil ed for each assumed name that is being withdrawn by the business entity. WHO MAY SIGN The Certificate of Withdrawal of Assumed Name must be signed by: • at least one partner authorized to do so by the partners of a Domestic or Foreign General Partnership (als o includes a Joint Venture); • at least one partner authorized to do so by the partners of a Domestic or Foreign Registered Limited Liability Partnership; • a general partner of a Domestic of Foreign Limited Partnership; • the trustees of a Domestic or Foreign Business Trust; • any person authorized to act for the Domestic or Foreign Corporation. • a member or manager author ized to act for the Domestic of Foreign Limited Liability Company. NUMBER OF COPIES Submit the original signed Certificate and at least one exact or conformed copy (may be a photocopy). All file-stamped copies will be returned to you as evidence of filing. One file-stamped copy must then be filed with the county cl erk of the county where the entity is deemed a resident for the purposes of and under the provisions of KRS Chapter 355. FILING FEE AND MAILING ADDRESS The filing fee is $20.00. Your check should be made payable to the “Kentucky State Treasurer”\ MAILING ADDRESS OFFICE LOCATION Trey Grayson Room 154 Capitol Building Secretary of State 700 Capital Avenue P O Box 718 Frankfort, KY 40601 Frankfort, KY 40602-0718 WEB SITE ADDRESS Our home page address is www.sos.ky.gov Click on “On Line Business Database” for informa tion on status of all business entities in Kentucky. Forms are also available on our web site. For further information, please call (502) 564-2848, press 2, and then press 5 or try our web site.