WITHDRAWAL NOTICE OF AN ASSUMED NAME 
 
 
NOTICE: This Certificate of Withdrawal properly executed is to be filed 
immediately with the Office of the Lieutenant Governor Corporation and 
Trademarks Section. 
 
 
NAME OF BUSINESS BEING ABANDONED 
 
 
 
        (Print or Type Name of Business) 
 
Address:________________________________________________________________ 
 
City: ____________________________ State:_________________ Zip Code _______ 
 
 
Give date original Assume Name were filed in this Office _______________________ 
 
 
Each of the undersigned has this day withdrawn from disposed of this interest in the 
above mentioned business and is no longer connected with the same, and will not be 
responsible for debts contracted by said business after filing of the withdrawal 
notice as prescribed by law. 
 
 
NAME ______________________________ SIGNATURE ______________________ 
 
ADDRESS ___________________________ ZIP CODE ________________________ 
 
NAME ______________________________ SIGNATURE ______________________ 
 
ADDRESS ___________________________ ZIP CODE ________________________ 
 
NAME ______________________________ SIGNATURE ______________________ 
 
ADDRESS ___________________________ ZIP CODE ________________________ 
 
 
 
 
 
 
 
 
 
______________, 20______ 
 
Before Me, THE UNDERSIGNED AUTHORITY, ON THIS DAY PERSONALLY APPEARED 
 
______________________________________________________________________________________ 
______________________________________________________________________________________ 
Known to me to be the person(s) whose name is subscribed to the foregoing instrument 
of writing and acknowledged to be the (she) (he) executed the same for the purpose and 
consideration therein expressed.