Pennsylvania Department of State — Certificate of Termination (Domestic Limited Liability Company) (15 Pa.C.S. § 8872(f)) (DSCB:15-8872(f)) Instructions

Enter the full name of the commercial registered office provider (the company or individual acting as the c/o provider) exactly as it should appear on the record.

Enter the name of the county in which the commercial registered office provider is located.

Enter the numeric day of the month on which the document is executed (e.g., 1–31).

Enter the month of execution as the month name or numeric month (e.g., January or 1 or 01).

Enter the four‑digit year in which the document is executed (e.g., 2023).

Enter the full legal name of the limited liability company as it should appear on the Certificate of Termination.

Provide the handwritten or typed name of the authorized representative signing this certificate to serve as their signature.

Enter the official title or position of the authorized representative who is signing the certificate (e.g., Managing Member, President).

Check this box when every debt, obligation and other liability of the limited liability company has been fully paid and discharged prior to termination.

Check this box when the company has made adequate provision (but not necessarily paid in full) for the payment and discharge of its debts, obligations and other liabilities prior to termination.

Check this box if, at the time of filing, there are no lawsuits, claims, or other actions pending against the limited liability company in any court.

Check this box if there are pending actions against the company but you have made adequate provision (e.g., reserves, bonds or other arrangements) to satisfy any judgment that may be entered in those actions.

Enter the full legal name of the limited liability company as it is registered with the Department of State.

Enter the current registered office address as on file: full street number and name, city, state, ZIP code, and county (all parts on this line).

Check this box if you want the completed document returned via email, and provide the email address on the adjacent line.

Enter the email address where you want the Department to return the completed document. Fill only if 'Return document by email to:' is 'Yes'.

Check this box when you want the Department of State to mail the completed document to the name and address you provide in the lines below.

Enter the primary mailing line for where the document should be returned (for example recipient name, company, or attention line). Fill only if 'Return document by mail to:' is 'Yes'.

Enter the full name of the person or entity to receive the returned document. Fill only if 'Return document by mail to:' is 'Yes'.

Enter the street address (street number, street name, and apartment or suite if applicable) for mailing the returned document. Fill only if 'Return document by mail to:' is 'Yes'.