Statement Of Conversion {DSCB 15-355}

PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Statement of Conversion DSCB:15-355 (7/1/2015) *355* 355 Return document by email to: _________________________________ Read all instructions prior to completing. Fee: $70 In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 355 (relating to Statement of conversion), the undersigned association, desiring to effect a conversion, hereby states that: A. For the converting association: 1. The name of the converting association is: _________________________________________________________ 2. The jurisdiction of formation of the converting association is: __________________________________________ 3. 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 Other ____________________ 4. Date on which the association was created, incorporated, formed or otherwise came into existence: _______________________________________________ (MM/DD/YYYY) 5. If the converting association is a domestic filing association (a Pennsylvania business corporation, nonprofit corporation, limited partnership, limited liability company, professional association or business trust), the statute under which it was first created, incorporated, formed or otherwise came into existence: ________________________________________________ (ex. Business Corporation Law of 1988, Limited Liability Company Law of 1994, etc.) American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-355-2 6. Check and complete one of the following addresses for the converting association. If the converting 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 (b) c/o: ______________________________________________________________________________________________ Name of Commercial Registered Office Provider County If the converting 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 converting 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: ____________________________________________________________________________________________________ Number and street City State Zip B. For the converted association: 1. The name of the converted association is: __________________________________________________________ 2. The jurisdiction of formation of the converted association is: ___________________________________________ 3. 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 Other ____________________ American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-355-3 4. Check and complete one of the following addresses for the converted association. If the converted association is a domestic filing association, domestic limited liability partnership or registered foreign association, its registered office address. Complete part (a) OR (b) ­ not both: (a) _________________________________________________________________________________________________ Number and street City State Zip County (b) c/o: ______________________________________________________________________________________________ Name of Commercial Registered Office Provider County If the converted 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 converted association is a nonregistered foreign association, complete both (1) and (2). (1) 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 (2) The name and address, including street and number, of its registered agent: ____________________________________________________________________________________________________ Name of Registered Agent ____________________________________________________________________________________________________ Number and street City State Zip C. Effective date of statement of conversion (check, and if appropriate complete, one of the following): This Statement of Conversion shall be effective upon filing in the Department of State. This Statement of Conversion shall be effective on: _________________________ at __________________. Date (MM/DD/YYYY) Hour (if any) D. Approval of conversion by converting association (check only one): For converting association that is a domestic entity ­ The plan of conversion was approved in accordance with 15 Pa.C.S. Chapter 3, Subchapter E (relating to conversion). For converting association that is a foreign association ­ The conversion was approved in accordance with the law of the jurisdiction of formation of the converting association. E. Attachments (see Instructions for required and optional attachments). IN TESTIMONY WHEREOF, the undersigned converting association has caused this Statement of Conversion to be signed by a duly authorized off