___________________________________
New Entity File Number
Filing Fee: $100 _______________________________________________________________ Approved: ______________
————— Submit in duplicate ————— Type or print clearly in black ink ————— Do not write above this line —————
Converting Entity Current file number: __________________________________
1. Converting Entity Name: __________________________________________________________________________
2. Current Entity Type: (select only one)
n For Profit Corporation
n Limited Liability Company n General Partnership
n Limited Liability Partnership n Limited Partnership n Not For Profit
3. Jurisdiction and Date of Incorporation/Organization: ____________________________________________________
4. The conversion is authorized by the law of the foreign entity’s jurisdiction of organization.
New Entity
5. Converted Entity Name: __________________________________________________________________________
6. Converted Entity Type: (select only one)
n For Profit Corporation
n Limited Liability Company n General Partnership
n Limited Liability Partnership
n Limited Partnership n Not For Profit
7. Jurisdiction of Incorporation/Organization: ____________________________________________________________
8. The Converted Entity: (select only one)
n intends to transact business in Illinois n will not be transacting business in Illinois (Please set forth address below.)
Address for Service of Process: ____________________________________________________________________
____________________________________________________________________
9. Effective Date of Conversion: If a future date is chosen, MUST be within 90 days of filing.
n Upon Filing
n Future Effective Date: ______________________________________
The Conversion was approved in accordance with Section 205 of the Entity Omnibus Act.
The formation document and fee for the Converted Entity must be attached.
10. The undersigned Entity has caused this statement to be signed by a duly authorized signer who affirms, under penalties
of perjury, that the facts stated herein are true and correct. All signatures must be in BLACK INK.
Dated _______________________________ , ________ ______________________________________
Month & Day Year Exact Name of Converting Entity
_________________________________________
Any Authorized Signer’s Signature
_________________________________________
Name and Title (type or print)
Printed by authority of the State of Illinois. January 2020 — 1 — C 349.3
EOA 205
Illinois Secretary of State
Department of Business Services
STATEMENT OF CONVERSION
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-6961
www.cyberdriveillinois.com
Remit payment in the form of a cashier’s
check, a certified check, a money order,
or an Illinois attorney’s or a CPA’s check
payable to Secretary of State.
(P.O. Box alone is not acceptable)
