Docketing Statement (Changes) {DSCB 15-134B}

PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Docketing Statement ­ Changes DSCB:15-134B (rev. 7/1/2015) BUREAU USE ONLY: Revenue ____ Labor & Industry ____ Other _________________________ Filed Date ________________ Part I. Complete for each filing: Current name of entity or association (survivor or new entity): Entity number, if known: __________________ State of formation: ________________________ Formation/foreign registration date in PA: __________________ Effective date, if any: ________________________ ____ Correction (complete Section A) ____ Division (complete Section C) ____ Abandonment (complete Section E) ____ Domestication (complete Section G) Part II. Check appropriate transaction: ____ Amendment (complete Section A) ____ Merger (complete Section B) ____ Conversion (complete Sections A and D) ____ Revival (complete Section F) ____ Dissolution before Commencement of Business (complete Section H) Section A ­ Amendment or Correction - Complete fields which pertain to changes: Name_____________________________________________________________________________________________ Registered Office: __________________________________________________________________________________ Number and street City State Zip County Purpose ___________________________________________________________________________________________ Stock (aggregate number of shares authorized): __________________ Term of Existence: _______________________ Effective Date: ___________________ Other: ________________________________________ Filing type to be amended or corrected: _____________________________________________ Section B ­ Merger - Complete Section A with any changes to the association surviving the merger, if any Merging entities not surviving the merger are: (attach sheet for additional merging entities) ___________________________________________________________________________________________________________ Name ____________________________________________________________________________________________________________ Effective Date Incorporation/foreign registration date in PA State of Jurisdiction ___________________________________________________________________________________________________________ Name ____________________________________________________________________________________________________________ Effective Date Incorporation/ foreign registration date in PA State of Jurisdiction American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-134B-2 Section C ­ Division - Complete Section A with any changes to the association surviving the division, if any Check only one: ____ Entity named in Part I survives ___ Entity named in Part I does not survive. Newly created entity(s) from the division are: (attach sheet for additional new entities) ___________________________________________________________________________________________________________ Name Entity Number ___________________________________________________________________________________________________________ Name Entity Number Section D ­ Conversion Type of converting association (check only one): ___ Business Corporation ___ Nonprofit Corporation ___ General Partnership ___ Limited Partnership ___ Limited Liability (General) Partnership ___ Limited Liability Limited Partnership ___ Limited Liability Company ___ Professional Association ___ Business Trust/Common Law Trust/Statutory Trust ___ Other _____________________________________ Jurisdiction ___________________________________ Section E ­ Abandonment Type of converted association (check only one): ___ Business Corporation ___ Nonprofit Corporation ___ General Partnership ___ Limited Partnership ___ Limited Liability (General) Partnership ___ Limited Liability Limited Partnership ___ Limited Liability Company ___ Professional Association ___ Business Trust/Common Law Trust/Statutory Trust ___ Other ____________________________________ Jurisdiction ___________________________________ ___________________________________________________ filed in the Department of State on ____________________________ Type of filing Date of filing Identify all entities involved (attach sheet for additional entities) ___________________________________________________________________________________________________________ Name Entity Number ___________________________________________________________________________________________________________ Name Entity Number Section F ­ Revival - complete Section A with any changes to revived association ___ Entity named in Part I hereby revives its charter or articles which were forfeited by Proclamation or expired. Section G ­ Domestication Domesticating jurisdiction ___________________________ Domesticated jurisdiction ________________________ Check if applicable ___ Domesticated entity is a nonregistered foreign association Section H ­ Dissolution before Commencement of Business ___ Entity named in Part I hereby dissolves prior to the commencement of business. American LegalNet, Inc. www.FormsWorkFlow.com