Form LLC-35.15
July 2017
Secretary of State Department of Business Services Limited Liability Division
501 S. Second St., Rm. 351 Springfield, IL 62756 217-524-8008 www.cyberdriveillinois.com
Payment may be made by check payabletoSecretaryofState.Ifcheck is returned for any reason this filing will be void.
Illinois
Limited Liability Company Act
Statement of Termination
SUBMIT IN DUPLICATE
Type or print clearly.
Filing Fee: $5
Approved:
FILE #
This space for use by Secretary of State.
1.Limited Liability Company name: ____________________________________________________________________
2.Post Office address to which a copy of any process against the Limited Liability Company that may be served on the Secretary of State may be mailed:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
3.The Limited Liability Company has been terminated.
4.The undersigned affirms, under penalties of perjury, having authority to sign hereto, that this Statement of Termination is to the best of my knowledge and belief, true, correct and complete.
Dated _________________________________, _______________
Month & Day Year
______________________________________________________________
Signature
______________________________________________________________
Name and Title (type or print)
______________________________________________________________
If applicant is signing for a company or other entity,
state name of company or entity.
RETURN TO: (Please type or print clearly.)
_____________________________________________
Name
_____________________________________________
Street
_____________________________________________
City, State, ZIP Code