<FormSubmission xmlns="http://xmlgw.companieshouse.gov.uk/Header" xmlns:bs="http://xmlgw.companieshouse.gov.uk" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://xmlgw.companieshouse.gov.uk/Header http://xmlgw.companieshouse.gov.uk/v1-0/schema/forms/FormSubmission-v2-8.xsd">
        <FormHeader>
                <CompanyNumber>01234567</CompanyNumber>
                <CompanyName>TEST COMPANY LIMITED</CompanyName>
                <CompanyAuthenticationCode>012345</CompanyAuthenticationCode>
                <PackageReference>9999</PackageReference>
                <FormIdentifier>PSCStatementWithdrawal</FormIdentifier>
                <SubmissionNumber>JS0100</SubmissionNumber>
                <ContactName>Test Team</ContactName>
                <ContactNumber>2034 8497</ContactNumber>
        </FormHeader>
        <DateSigned>2010-05-15</DateSigned>
        <Form>
            <PSCStatementWithdrawal xsi:schemaLocation="http://xmlgw.companieshouse.gov.uk http://xmlgw.companieshouse.gov.uk/v1-0/schema/forms/PSCStatementWithdrawal-v1-1.xsd" xmlns="http://xmlgw.companieshouse.gov.uk" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
                        <PSCLinkedStatement>
                                <Statement>PSC_HAS_FAILED_TO_CONFIRM_CHANGED_DETAILS</Statement>
                               <Individual>
                                        <Surname>Last</Surname>
                                        <Forename>First</Forename>
                                        <PartialDOB>
                                                <Month>05</Month>
                                                <Year>1977</Year>
                                        </PartialDOB>
                                </Individual>
                        </PSCLinkedStatement>
                    <WithdrawalDate>2016-04-07</WithdrawalDate>
                    <RegisterEntryDate>2016-04-06</RegisterEntryDate>
                </PSCStatementWithdrawal>
	</Form>
</FormSubmission>
