Free Statement of Dissociation - Illinois

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FORM UPA-704
January 2004

Illinois Uniform Partnership Act
Statement of Dissociation
Submit in duplicate. Please type or print clearly. This space for use by Secretary of State. Date: Assigned File #: Filing Fee: $25 Approved:

This space for use by Secretary of State.

Secretary of State Department of Business Services LLP/RLLP Division Uniform Partnership Section 357 Howlett Building Springfield, IL 62756 217-785-8960 www.cyberdriveillinois.com

1. Partnership Name: 2. File Number: 3. Partner dissociated from partnership:

(Name must be stated exactly as on record with the Secretary of State.)

Federal Employer Identification Number:

I/We declare the above-named partner(s) to be dissociated from the Limited Liability Partnership. I/We declare under the penalty of perjury, under the laws of the State of Illinois, that the foregoing is true, correct and complete. Executed on the
Day

of
Month

,
Year

by a partner.

If filed by a dissociating partner, the dissociating partner must sign.
Signature Number, Street Address

Name and Title (type or print)

City, State, ZIP

If filed by the partnership, two partners must sign.
Signature Number, Street Address

Name and Title (type or print)

City, State, ZIP

Signature

Number, Street Address

Name and Title (type or print)

City, State, ZIP

Please submit this form in duplicate along with the $25 filing fee. Signatures must be in BLACK INK on an original document.
Printed by authority of the State of Illinois. January 2008 - 200 - UPA 10.2