Statement Of Withdrawal Of Foreign Registration {DSCB 15-415-417}

PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Return document by email to: _________________________________ Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/. Fee: $250 In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 413 (relating to amendment of foreign registration statement), the undersigned registered foreign association hereby states that: 1. The name of the association under which it is registered to do business in this Commonwealth is: 2. The type of association is (check only one): Business Corporation Nonprofit Corporation Limited Liability Company Limited Partnership Limited Liability (General) Partnership Limited Liability Limited Partnership Business Trust Professional Association 3. The (a) address of the association's 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 4. Effective date of amendment of foreign registration (check, and if appropriate complete, one of the following): The Amendment of Foreign Registration shall be effective upon filing in the Department of State. The Amendment of Foreign Registration shall be effective on: ________________________ at _______________. Date (MM/DD/YYYY) Hour (if any) American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-413 - 2 5. Check, and if appropriate complete, one of the following: The association desires that its registration be amended to change or correct the following information: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ The amendment adopted by the association is set forth in full in Exhibit A attached hereto and made a part hereof. If the amendment reflects a change in name for the association which does not comply with 15 Pa.C.S. § 414 and §§ 201-209, the foreign association must adopt an alternate name that complies with 15 Pa.C.S. §§ 201-209 for use in Pennsylvania. IN TESTIMONY WHEREOF, the undersigned association has caused this Amendment of Foreign Registration Statement to be signed by a duly authorized representative thereof this ______________ day of ____________________________ 20__________. ______________________________________ Name of Association ___________________________________________________ Signature ___________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-413­Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Website: 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. The nonrefundable filing fee for this form is $250. Checks should be made payable to the Department of State. Checks must contain a commercially pre-printed name and address. This form and all accompanying documents shall be mailed to the address stated above. Who should file this form? A foreign association that is registered to do business in this Commonwealth must deliver to the Department for filing an amendment to its foreign registration statement if there is a change in any of the following: (1) The name of the association. (2) The type of association, including, if it is a foreign limited partnership, whether the association became or ceased to be a foreign limited liability limited partnership. (3) The association's jurisdiction of formation. (4) An address required by section 412(a)(4) (relating to foreign registration statement). (5) Its registered office. (6) The authority of the association to have one or more series. Applicable Law For foreign associations, in general, 15 Pa.C.S. §§ 102; 401419; for amendment, 15 Pa.C.S. § 413; for names, 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. Attachments 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). If Consent cannot be obtained, the association may adopt, for the purpose of doing business in this Commonwealth, an alternate name that complies with 15 Pa.C.S. § 414 and §§ 201-209. (3) Any necessary governmental approvals. 1. Give the exact name of the association as registered to do business in Pennsylvania and as on file with the Department of State. If a foreign association has adopted an alternate name in order to register to do business in Pennsylvania, the registered foreign association must use the alternate name in response to a requirement that a document delivered to the Department for filing state the name of the association. This field is required. 2. Select the type of association. Only one option may be selected. This field is required. 3. Give one of the following: the current registered office address in the Commonwealth in (a) or the name of a Commercial Registered Office Provider (b) and the county of venue, as on file with the Department of State at the time the amendment is submitted for filing. 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. 4. Any date specified as the effective date of the Amendment of Foreign Registration must be a future effective date (after the date and time of its delivery to the Department