Fictitious Name Amendment Withdrawal Cancellation {DCSB 54-312}

PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Fictitious Name Amendment, Withdrawal, Cancellation DSCB:54-312/313 (rev. 7/2015) *3123* 3123 Withdrawal (§ 313) Cancellation (§ 313) Return document by email to: ________________________________ Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/. Fee: $70 Check one: Amendment (§ 312) In compliance with the requirements of 54 Pa.C.S. Ch.3 (relating to fictitious names), the undersigned entity or entities, desiring to amend, withdraw or cancel from a fictitious name registration, hereby state(s) that: 1. The fictitious name is: 2. The address of the principal place of business, including number and street, if any, is: Number and street City State Zip County 3. The last preceding filing with respect to this fictitious name was made in the Department on . Date (MM/DD/YYYY) 4. A brief statement of the character or nature of the business or other activity to be carried on under or through the fictitious name is: American LegalNet, Inc. www.FormsWorkFlow.com DSCB:54-312/313­2 5. Check one or more of the following, as appropriate: The fictitious name has been changed to: The principal place of business set forth in paragraph 2 has been changed to (PO Box alone not acceptable): Number and street City State Zip County The following party(ies) has (have) been added to the registration and their signature(s) appear(s) at the end of this application. Name Number and street City State Zip The following party(ies) has (have) withdrawn from the business and their signature(s) appear(s) at the end of this application. Name Number and street City State Zip The fictitious name registration is cancelled. 6. Check box for Application for Amendment Only: This amendment, without reference to any other filing sets forth all information with respect to the fictitious name which would be required in an original filing under the Fictitious Names Act. 7. Optional-See Instruction F: This application has been executed by an agent heretofore designated for that purpose in a prior filing in this registration. American LegalNet, Inc. www.FormsWorkFlow.com DSCB:54-312/313-3 IN TESTIMONY WHEREOF, the undersigned has (have) caused this Application for Amendment, Withdrawal or Cancellation of/from Fictitious Name to be executed this day of , . Adding party(ies) signature(s) ___________________________ ___________________________ ___________________________ Withdrawing party(ies) signature(s) ___________________________ ___________________________ ___________________________ All current party(ies) signature(s) ___________________________ ___________________________ ___________________________ ___________________________ Name of Entity ___________________________ Signature ___________________________ Title ___________________________ Name of Entity ___________________________ Signature ___________________________ Title ___________________________ Name of Entity ___________________________ Signature ___________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:54-312/313­Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Web site: www.dos.pa.gov/corps Instructions for Completion of Form: A. Typewritten is preferred. If handwritten, the form shall be legible and completed in black or blue-black ink in order to permit reproduction. The nonrefundable filing fee for this form is $70 made payable to the Department of State. Checks must contain a commercially pre-printed name and address. Enter the name and mailing address to which any correspondence regarding this filing should be sent. This field must be completed for the Bureau to return the filing. If the filing is to be returned by email, an email address must be provided. An email will be sent to address provided, containing a link and instructions on how a copy of the filed document or correspondence may be downloaded. Any email or mailing addresses provided on this form will become part of the filed document and therefore public record. B. 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. C. The following, in addition to the filing fee, shall accompany this form: (1) If the amendment effects a change of name, any necessary copies of form DSCB:19-17.2 (Consent to Appropriation of Name). (2) Any necessary governmental approvals. D. For general instructions relating to fictitious name registration see 19 Pa. Code Subch. 17C (relating to Fictitious names). These instructions relate to such matters as voluntary and mandatory registration, general restrictions on name availability, use of corporate designators, agent for effecting amendments, etc., execution, official advertising when an individual is a party to the registration, and effect of registration and non-registration. E. The name of a commercial registered office provider may not be used in Paragraph 2 or 4B in lieu of an address. F. An amendment or cancellation shall be signed by all parties to the registration immediately preceding the filing unless an agent is authorized in the original registration and the agent signs the application. If the amendment adds a new party, the party added by the amendment must sign the form. In the case of withdrawal, the form need only be signed by the withdrawing party. G. If the filing involves a deceased party, the form should be signed by an executor or other fiduciary. It is not necessary to submit a short certificate showing appointment as fiduciary, etc. See 15 Pa.C.S. § 135(b). H. There is no requirement that the parties involved in an amended, canceled or withdrawal application advertise their intention to file or the filing of such application. I. No certificate will be issued by the Department in response to this filing. J. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkFlow.com