Statement Of Conversion {CORP-3(P)(CONV)}

File No.: Business ID: Processed by: FOR OFFICE USE ONLY Vermont Secretary of State STATEMENT OF CONVERSION of a Converting or Converted Corporation 1.RETURN ACKNOWLEDGEMENT TO: Required - Name and Address. Name Address Address Address Please review instructions page before beginning. This document must be typewritten or printed (11A V.S.A. 247 1.20). 11A V.S.A. 247 11.06 DIVISION OF CORPORATIONS FORM CORP-3(P)(CONV) (REV 07/01/17) Page 1 of 1 LLC CONVERSION 2 . CONVERTING ENTITY : Required 226 The entity in existence prior to this conversion Note: A Trade Name (D BA ) is not an entity and therefore cannot be a converting or converted entity a. BUSINESS NAME: b. BUSINESS ID: c.JURISDICTION OF FORMATION: Required - Select one (1) and only one:Vermont.-A converting domestic corporation for profit may become a converted domestic entity that is a different type of entity. -a domestic converting entity that is not a domestic corporation for profit may become a domestic corporation for profit. The Plan of Conversion was approved in accordance with 11A V.S.A. Ch. 11. Other: If Selected - U.S. State or Non-U.S. Country -A foreign entity that is not a foreign corporation may become a domestic corporation for profit. This conversion was approved by the converting entity in accordance with its governing statute in its jurisdiction of formation . 3 . CONVERTED ENTITY: Required 226 The entity in existence following this conversion a . NEW BUSINESS NAME: Required b. BUSINESS ID: c. NEW BUSINESS TYPE: Required - S elect one (1) and only one of the following Limited Liabilit y Company (LLC/PLC/L3C ) Profit Corporation Nonprofit MBE LLP LP Partnership General e. A fully executed registration document, complete with statutory fee, for the converted entity listed above (Line 3a.) is attached. 4 . EFFECTIVE DATE: Optional 5. CERTIFICATION OF STATEMENT: Required I/We Hereby Certify, Under Penalty Of Law Or Perjury (11 V.S.A. 247 4029 & 13 V.S.A. 247 2904), That All Above Statements AndInformation Is Accurate, And Provided With The Required Documents Attached With Any Requisite Statutory Fees For AttachedDocuments, A Self-Addressed Stamped Envelope, And A Check Or Money Order For $20.00 (11 V.S.A 247 4012(18)) Made Payable To 223VT SOS.224 Printed Name of Authorizer Signature Date Required - Must be principal of converting entity Printed Name of 2nd Authorizer (General Partner) Signature Date Required only if converting entity is a general partnership or limited liability partnership American LegalNet, Inc. www.FormsWorkFlow.com