Statement Of Revival - Domestic Corporation) {DSCB 15-1341-5341}

PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Statement of Revival Domestic Corporation DSCB:15-1341/5341 (rev. 7/2015) *1341* 1341 Nonprofit Corporation (§ 5341) Return document by email to: _________________________________ Read all instructions prior to completing. Fee: $70 Check one: Business Corporation (§ 1341) In compliance with the requirements of the applicable provisions (relating to statement of revival), the undersigned forfeited or expired corporation, desiring to procure a revival of its charter or articles, hereby states that: 1. The name of the corporation at the time its charter or articles were forfeited or expired is: 2. The (a) address of this corporation's last registered office in this Commonwealth as on file with the Department or (b) name of its commercial registered office provider and the county of venue, as on file with the Department, is: (Complete only (a) or (b), not both) (a) Number and Street City State Zip County (b) Name of Commercial Registered Office Provider c/o: County 3. The statute by or under which it was incorporated: ________________________________________ 4. The date of its incorporation: ____________________________ (MM/DD/YYYY) American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-1341/5341­2 5. (Strike out if inapplicable): The name the corporation adopted as its new name, in view of the prior appropriation of its former name by a senior corporation is: 6. The (a) address of this corporation's current registered office in this Commonwealth or (b) name of its commercial registered office provider and the county of venue is: (Complete only (a) or (b), not both) (a) Number and Street City State Zip County (b) Name of Commercial Registered Office Provider c/o: County 7. Check and complete one of the following: The charter or articles of the corporation were forfeited by declaration under Section 1704 of the act of April 9, 1929 (P.L.343, No.176), known as The Fiscal Code and published at , Pa.B. . The charter or articles of the corporation expired by their own terms under the provisions of the charter or articles set forth in full in Exhibit A attached hereto and made a part hereof. 8. The corporate existence of the corporation shall be revived. 9. The filing of this statement has been authorized by the corporation. IN TESTIMONY WHEREOF, the undersigned corporation has caused this Statement of Revival to be executed this day of , . Name of Corporation Signature Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-1341/5341 - Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 web site: www.dos.pa.gov/corps Instructions for Completion of Form: A. Typewritten is preferred. If handwritten, the form shall be legible and completed in black or blue-black ink in order to permit reproduction. The nonrefundable filing fee for this form is $70 made payable to the Department of State. Checks must contain a commercially pre-printed name and address. Enter the name and mailing address to which any correspondence regarding this filing should be sent. This field must be completed for the Bureau to return the filing. If the filing is to be returned by email, an email address must be provided. An email will be sent to address provided, containing a link and instructions on how a copy of the filed document or correspondence may be downloaded. Any email or mailing addresses provided on this form will become part of the filed document and therefore public record. B. Under 15 Pa.C.S. § 135(c) (relating to addresses) an actual street or rural route box number must be used as an address, and the Department of State is required to refuse to receive or file any document that sets forth only a post office box address. C. The following, in addition to the filing fee, shall accompany this form: (1) One copy of a completed form DSCB:15-134B (Docketing Statement-Changes). (2) Any necessary copies of form DSCB:19-17.2 (Consent to Appropriation of Name). (3) In the case of a forfeited corporation, tax clearance certificates from the Department of Revenue and from the Bureau of Employment Security of the Department of Labor and Industry evidencing payment of all taxes and charges payable to the Commonwealth. (4) Nonprofit Corporation ­ Any necessary governmental approvals. D. There is no official publication requirement incident to the filing of this form. E. A forfeited or expired corporation may authorize the filing of this form by action of its last directors or may elect directors and officers under the Business/Nonprofit Corporation Law of 1988 for the limited purpose of authorizing the filing. F. The corporation may not revive its corporate charter where it has been revoked by a court proceeding instituted by the Attorney General's Office under 15 Pa.C.S. § 503 (relating to actions to revoke corporate franchises). G. This form and all accompanying documents shall be mailed to the above stated address. 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