Statement Of Merger Addendum {DSCB 15-335AD}

PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Statement of Merger - Addendum DSCB:15-335AD (7/1/2015) *335Ad* 335Ad This form is used to identify additional merging parties and must be submitted with the Statement of Merger form (DSCB:15-335). B. For the merging association(s) that are not surviving the merger (continued): 1. The name of the merging association is: ____________________________________________________________ 2. The jurisdiction of formation of the merging association: ______________________________________________ 3. The type of association is (check only one): Business Corporation Limited Partnership Nonprofit Corporation Limited Liability (General) Partnership Limited Liability Company Limited Liability Limited Partnership 4. Check and complete one of the following addresses. If the merging association is a domestic filing association, domestic limited liability partnership or registered foreign association, the current registered office address as on file with the Department of State. Complete part (a) OR (b) ­ not both: (a) _________________________________________________________________________________________________ Number and street City State Zip County Business Trust Professional Association Other ___________________ (b) c/o: ______________________________________________________________________________________________ Name of Commercial Registered Office Provider County If the merging association is a domestic association that is not a domestic filing association or limited liability partnership, the address, including street and number, if any, of its principal office: ____________________________________________________________________________________________________ Number and street City State Zip County If the merging association is a nonregistered foreign association, the address, including street and number, if any, of its registered or similar office, if any, required to be maintained by the law of its jurisdiction of formation; or if it is not required to maintain a registered or similar office, its principal office address: ____________________________________________________________________________________________________ Number and street City State Zip IN TESTIMONY WHEREOF, the undersigned association has caused this Statement of Merger-Addendum to be signed by an authorized officer thereof this ______________ day of ____________________________, 20________. ______________________________________ Name of Merging Association ______________________________________ Signature ______________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com '6&%$',QVWUXFWLRQV 3HQQV\OYDQLD 'HSDUWPHQW RI 6WDWH %XUHDX RI &RUSRUDWLRQV DQG &KDULWDEOH 2UJDQL]DWLRQV 32 %R[ +DUULVEXUJ 3$  ZHE VLWH ZZZGRVSDJRYFRUSV 7\SHZULWWHQ LV SUHIHUUHG ,I KDQGZULWWHQ WKH IRUP PXVW EH OHJLEOH DQG FRPSOHWHG LQ EODFN RU EOXHEODFN LQN LQ RUGHU WR SHUPLW UHSURGXFWLRQ 7KLV IRUP DQG DOO DFFRPSDQ\LQJ GRFXPHQWV VKDOO EH PDLOHG WR WKH DGGUHVV 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