Certificate Of Conversion For Entities Converting Within Or Off The Records {700}

Last Revised: 06/2019Page 1 of 8Form 700 Toll Free: 877.767.3453 | Central Ohio: 614.466.3910 OhioSoS.gov | business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Filing Form Cover LetterPlease return the approval certificate to: Address: City: ZIP Code: Phone Number: E-mail Address: Check here if you would like to receive important notices via e-mail from the Ohio Secretary of State's office regarding Business Services. Check here if you would like to be signed up for our Filing Notification System for the business entity being created or updated by filing this form. This is a free service provided to notify you via e-mail when any document is filed on your business record. Please make checks or money orders payable to: "Ohio Secretary of State" Type of Service Being Requested: (PLEASE CHECK ONE BOX BELOW) Regular Service: Only the filing fee listed on page one of the form is required and the filing will be processed in approximately 3-7 business days. The processing time may vary based on the volume of filings received by our office. Expedite Service 1: By including an Expedite fee of $100.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 2 business days after it is received by our office. Expedite Service 2: By including an Expedite fee of $200.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 1 business day after it is received by our office. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Expedite Service 3: By including an Expedite fee of $300.00, in addition to the regular filing fee on page one of the form, the filing will be processed within 4 hours after it is received by our office, if received by 1:00 p.m. This service is only available to walk-in customers who hand deliver the document to the Client Service Center. Preclearance Filing: A filing form, to be submitted at a later date for processing, may be submitted to be examined for the purpose of advising as to the acceptability of the proposed filing for a fee of $50.00. The Preclearance will be complete within 1-2 business days. Name (Individual or Business Name): To the Attention of (if necessary): State American LegalNet, Inc. www.FormsWorkFlow.com Last Revised: 06/2019Page 2 of 8Form 700Toll Free: 877.767.3453 Central Ohio: 614.466.3910 OhioSoS.gov business@OhioSoS.gov File online or for more information: OhioBusinessCentral.gov Mail this form to one of the following: Regular Filing (non expedite) P.O. Box 1329 Columbus, OH 43216 Expedite Filing (Two business day processing time. Requires an additional $100.00) P.O. Box 1390 Columbus, OH 43216 Certificate for Conversion for Entities Converting Within or Off the Records of the Ohio Secretary of State Filing Fee: $99 Form Must Be Typed (CHECK ONLY ONE (1) BOX) The converting entity is a: (Check Only (1) One Box) The converting entity hereby states that it has complied with all laws in the jurisdiction under which it exists and that those laws permit the conversion. Converting Within The Records of the Ohio Secretary of State Converting Off The Records of the Ohio Secretary of State (187-VXX) Name of the converting entity Jurisdiction of Formation Charter/Registration Number Domestic Nonprofit Corporation Domestic For-Profit Corporation Foreign Nonprofit Corporation Foreign For-Profit Corporation Domestic Nonprofit Limited Liability Company Foreign Nonprofit Limited Liability Company Domestic For-Profit Limited Liability Company Foreign For-Profit Limited Liability Company Partnership Domestic Limited Partnership Foreign Limited Partnership Domestic Limited Liability Partnership Foreign Limited Liability Partnership(1)(2)Form 700 Prescribed by: For screen readers, follow instructions located at this path. American LegalNet, Inc. www.FormsWorkFlow.com Last Revised: 06/2019Page 3 of 8Form 700 The converted entity is a: (Check Only (1) One Box) Name of the converted entity Jurisdiction of Formation (The conversion is effective upon the filing of this certificate or on a later date specified in the certificate) Name and address of the person or entity that will provide a copy of the declaration of conversion upon written request. Domestic For-Profit Corporation Domestic Professional Association Foreign Nonprofit Corporation Foreign For-Profit Corporation Domestic Nonprofit Limited Liability Company Foreign Nonprofit Limited Liability Company Domestic For-Profit Limited Liability Company Foreign For-Profit Limited Liability Company Partnership Domestic Limited Partnership Foreign Limited Partnership Domestic Limited Liability Partnership Foreign Limited Liability Partnership Name Mailing Address City Zip Code If the converting entity is a domestic or foreign entity that will not be licensed in Ohio, provide the name and address of the statutory agent upon whom any process, notice or demand may be served. Required information that must accompany conversion certificate if box 2 is checked See instructions for additional filing requirements if (1) the conversion creates a new domestic entity, (2) the converted entity is a foreign entity that desires to transact business in Ohio; or (3) if a domestic corporation or foreign corporation licensed in Ohio is the converting entity. State Effective Date (MM/DD/YYYY) Name of Statutory Agent Mailing Address City State ZIP Code(Optional) American LegalNet, Inc. www.FormsWorkFlow.com Last Revised: 06/2019Page 4 of 8Form 700 Print Name By (if applicable) Signature Print Name By (if applicable) Signature Print Name By (if applicable) SignatureBy signing and submitting this form to the Ohio Secretary of State, the undersigned hereby certifies that he or she has the requisite authority to execute this document.Required Must be signed by an authorized representative. American LegalNet, Inc. www.FormsWorkFlow.com Last Revised: 06/2019Page 5 of 8Form 700 Name of Corporation The corporation is not required to pay or the department of taxation has not assessed any personal property tax. Signature Title Name Mailing Address City State ZIP Code Notary Public Date Notified (MM/DD/YYYY) Sworn to and subscribed in my presence on this date (MM/DD/YYYY)AFFIDAVITComplete the information in this section.In lieu of dissolution releases from various governmental authorities.The undersigned, being first duly sworn, declares that on the dates indicated below, each of the named state governmental agencies was advised IN WRITING of the scheduled date of filing of the Certificate and was advised IN WRITING of the acknowledgement by the corporation of the applicability of the provisions of section 1701.95 of the ORC. AgencyOhio Bureau of Workers'Compensation 30 W. Spring Street Columbus, Ohio 43215* Only required for domestic for-profit corporationsAgencyOhio Job & Family Services Status and Liability Section Data Correspondence Control Fax: 614-752-4811 Phone: 614-466-2319AgencyNote: This affidavit must be signed by one or more persons executing the certificate or by an officer of the corporation.SealOvernight Address: P.O. Box 182413 Columbus, OH 43218-2413Regular Address: P.O. Box 182413 Columbus, OH 43218-2413Ohio Department of Taxation Taxpayer Services/Tax Release Unit P.O. Box 182382 Columbus, OH 43218-2382 Dissolution@tax.state.oh.us * Complete this date notified field only if the corporation is a domestic non-profit corporation or foreign corporation. * Note: Domestic for-profit corporations must submit with this filing a Certificate of Tax Clearance issued by the Ohio Department of Taxation. Date Commission Expires (MM/DD/YYYY) Date Notified (MM/DD/YYYY) Date Notified (MM/DD/YYYY) American LegalNet, Inc. www.FormsWorkFlow.com Last Revised: 06/2019Page 6 of 8Form 700 State of County of Name of Officer Title of Officer Name of Corporation and that this affidavit is made in compliance with Ohio Revised Code Section Has no personal property in any county in Ohio Is the type required to pay personal property taxes to state authorities only Has personal property in the following county (ies) County County County Sworn