Legal Deregistration Statement

LEGAL DEREGISTRATION STATEMENT

This Legal Deregistration Statement ("Statement") is made as of by and between Registrant Name: , an entity organized as: Corporation LLC Individual Other with principal place of business at (hereinafter "Registrant"), and Registrar Name: , with principal place of business at (hereinafter "Registrar").

RECITALS

WHEREAS, Registrant is the record holder of the registration identified as Registration Number: registered in the jurisdiction of ;

WHEREAS, Registrant desires to terminate and remove the registration referenced above and to instruct Registrar to effect such deregistration in accordance with applicable law and the terms of this Statement;

WHEREAS, Registrar is willing to accept Registrant's instruction to deregister the registration, subject to the representations, warranties, and indemnities contained herein and any fees or charges payable by Registrant.

NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth below, the parties agree as follows:

1. DEFINITIONS

1.1. "Deregistration" means the cancellation, removal, termination or withdrawal of the Registration Number described above from the applicable register or record maintained by the Registrar or any governmental or private registry.

1.2. "Effective Deregistration Date" means the date on which Registrar completes all administrative steps required to remove the registration, which shall be on or after the requested Deregistration Date submitted by Registrant.

2. AUTHORIZATION AND INSTRUCTIONS

2.1. Registrant hereby authorizes and instructs Registrar to effect Deregistration of the registration identified above and to take all necessary and customary steps to accomplish such Deregistration, including preparing, filing, submitting, and delivering any notices, forms, certificates or instruments required by the applicable registry or authority.

2.2. Registrant requests that the Deregistration be effective on or after (the "Requested Date"). Registrar will use commercially reasonable efforts to obtain an Effective Deregistration Date on or as soon after the Requested Date as practicable, but Registrar makes no guarantee of a specific Effective Deregistration Date.

3. REPRESENTATIONS AND WARRANTIES

Registrant represents and warrants to Registrar, and acknowledges that Registrar is relying upon such representations and warranties, that:

3.1. Registrant is duly authorized and has full power and authority to execute and deliver this Statement and to perform its obligations hereunder. The person executing this Statement on behalf of Registrant is duly authorized to do so.

3.2. The registration is owned solely by Registrant and is not subject to any lien, encumbrance, adverse claim, or court order that would prevent or restrict Deregistration, except as disclosed in the following description:

3.3. Registrant has provided all information and documentation reasonably required by Registrar to carry out Deregistration and has not omitted any material fact known to Registrant that would materially impair Registrar's ability to effect Deregistration.

4. INDEMNIFICATION

Registrant shall defend, indemnify and hold harmless Registrar and its affiliates, officers, directors, employees and agents from and against any and all losses, liabilities, claims, damages, costs and expenses (including reasonable attorneys' fees and costs) arising out of or resulting from (a) any breach of the representations and warranties in Section 3, (b) any third-party claim relating to Registrant's authority to request Deregistration, or (c) Registrant's failure to obtain any consents or releases required to effect Deregistration.

5. FEES, COSTS AND EXPENSES

Registrant shall be responsible for all fees, taxes, duties and costs charged by any registry, governmental authority or third party in connection with Deregistration and for Registrar's reasonable service fees as agreed between the parties. Registrant acknowledges that fees may be payable prior to Registrar's performance. Agreed fee (if any): .

6. CONFIDENTIALITY

Each party shall maintain as confidential and shall not disclose to any third party any non-public information received from the other party in connection with this Statement, except as required by law, court order, or to the extent necessary to effectuate the Deregistration or to enforce the terms of this Statement.

7. NOTICES

Registrant Notice Address

Registrant Contact (email or phone)

Registrar Notice Address

Registrar Contact (email or phone)

All notices provided under this Statement shall be in writing and shall be deemed given when delivered personally, sent by nationally recognized overnight courier, or sent by certified mail, return receipt requested, to the addresses specified in this Section or to such other address as either party may designate in writing in accordance with this Section.

8. AMENDMENT; WAIVER

Any amendment or modification of this Statement must be in writing and signed by authorized representatives of both parties. No waiver of any provision of this Statement shall be effective unless in writing and signed by the party against whom the waiver is asserted.

9. GOVERNING LAW; JURISDICTION

This Statement shall be governed by and construed in accordance with the laws of the state or jurisdiction of without regard to its conflicts of law principles. The parties submit to the exclusive jurisdiction of the courts located in that jurisdiction for any disputes arising out of this Statement.

10. ENTIRE AGREEMENT; SEVERABILITY

This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and representations, whether written or oral. If any provision of this Statement is held to be invalid, illegal or unenforceable, the remaining provisions shall remain in full force and effect.

11. COUNTERPARTS; EXECUTION

This Statement may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument. Electronic signatures, including scanned signatures and electronic signing platforms, are acceptable and shall be binding for all purposes.

ADDITIONAL INFORMATION

Reason for Deregistration (briefly describe business reason, dissolution, consolidation, error correction, or other basis):

Additional remarks or instructions to Registrar:

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