Consent To Appropriation Of Name {DSCB 19-17.2}

PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Consent to Appropriation of Name DSCB:19-17.2 (rev. 7/2015 *19172* 19172 Pursuant to 19 Pa. Code § 17.2 (relating to appropriation of the name of a senior corporation), the undersigned association, desiring to consent to the appropriation of its name by another association, hereby certifies that: 1. The name of the association executing this Consent to Appropriation of Name is: 2. The (a) address of the consenting association's current registered office in this Commonwealth or (b) name of its commercial registered office provider and the county of venue is: Complete part (a) OR (b) ­ not both: (a) ________________________________________________________________________________________________________ Number and street City State Zip County OR (b) c/o: _____________________________________________________________________________________________________ Name of Commercial Registered Office Provider County 3. The date of incorporation or other organization of the consenting association is: _______________________________ 4. The association(s) entitled to the benefit of this Consent to Appropriation of Name is(are): 5. The consenting association is (check only one): About to change its name About to cease to do business Being wound up A foreign association about to withdraw from doing business in the Commonwealth IN TESTIMONY WHEREOF, the undersigned association has caused this Consent to Appropriation of Name be signed by a duly authorized officer thereof this day of , 20 . Signature Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:19-17.2­Instructions 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 General Information Typewritten is preferred. If handwritten, the form must be legible and completed in black or blue-black ink in order to permit reproduction. There is no fee for this document. Who should complete this form? A domestic filing entity, a domestic limited liability partnership, an electing partnership, a registered foreign association or an association registered at any time under 54 Pa.C.S. Ch. 5 (relating to corporate and other association names) may consent to the use of its name by another association as long as the consenting association has stated that it is about to change its name, is about to cease to do business, is being wound up or is a foreign association about to withdraw from doing business in this Commonwealth, and the statement and a consent to the adoption of the name are delivered to the Department of State for filing. This form will be deemed to be incorporated by reference into the filing to which it relates, e.g., articles of incorporation, articles of amendment effecting a change of name, articles of merger effecting a change of name, articles of division, application for a certificate of authority, application for an amended certificate of authority, certificate of limited partnership, amended certificate of limited partnership effecting a change of name, documents merging a partnership or other association effecting a change of name, instrument with respect to a business trust, amended instrument with respect to a business trust effecting a change of name, etc. Therefore an executed copy (which may be a photocopy) of this form should be attached to each copy of the filing to which it relates which is submitted to the Department and no separate docketing statement should be submitted with respect to this form. Applicable Law For names, in general, see 15 Pa.C.S. § 414 and §§ 201-209. Statutes are available on the Pennsylvania General Assembly website, www.legis.state.pa.us, by following the link for Statutes. Instructions for Completion of Form: 1. Give the exact name of the consenting association. The name on this line must match exactly the association name as shown in Department's records at the time the Consent for Appropriation is submitted for filing. This field is required. 2. The address provided must be of the consenting association's registered office (a) or Commercial Registered Office Provider (b) as on file with the Department of State. Post office boxes are not acceptable for any address. 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. This field is required. 3. Give the date on which the consenting association was originally incorporated or formed. Provide month, day and year. This field is required. 4. Give the exact name(s) of the association(s) that will use the name. This field is required. 5. Check and complete one of the boxes, based on the status or situation of the consenting association. This field is required. Signature and Verification An authorized representative of the consenting association must sign the Consent to Appropriation of Name. Signing a document delivered to the Department for filing is an affirmation under the penalties provided in 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) that the facts stated in the document are true in all material respects. This field is required. American LegalNet, Inc. www.FormsWorkFlow.com