Fillable Docketing Statement Changes (Pennsylvania)

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Docketing Statement Changes (Pennsylvania)

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PENNSYLVANIA DEPARTMENT OF STATE
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
Part I. Complete for each filing:
Current name of entity or association (survivor or new entity):
Entity number, if known: __________________ Formation/foreign registration date in PA: __________________
State of formation: ________________________ Effective date, if any: ________________________
Part II. Check appropriate transaction:
____ Amendment (complete Section A) ____ Correction (complete Section A)
____ Merger (complete Section B) ____ Division (complete Section C)
____ Conversion (complete Sections A and D) ____ Abandonment (complete Section E)
____ Revival (complete Section F) ____ Domestication (complete Section G)
____ 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): __________________ Effective Date: ___________________
Term of Existence: _______________________ 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
BUREAU USE ONLY:
Revenue ____ Labor & Industry ____ Other _________________________ Filed Date ________________
Docketing Statement – Changes
DSCB:15-134B
(rev. 7/1/2015)
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): Type of converted association (check only one):
___ Business Corporation ___ Business Corporation
___ Nonprofit Corporation ___ Nonprofit Corporation
___ General Partnership ___ General Partnership
___ Limited Partnership ___ Limited Partnership
___ Limited Liability (General) Partnership ___ Limited Liability (General) Partnership
___ Limited Liability Limited Partnership ___ Limited Liability Limited Partnership
___ Limited Liability Company ___ Limited Liability Company
___ Professional Association ___ Professional Association
___ Business Trust/Common Law Trust/Statutory Trust ___ Business Trust/Common Law Trust/Statutory Trust
___ Other _____________________________________ ___ Other ____________________________________
Jurisdiction ___________________________________ Jurisdiction ___________________________________
Section E – Abandonment
___________________________________________________ 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.
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Docketing Statement Changes (Pennsylvania)

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Completed 9 February 2021

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