Non-Refundable Processing Fee: $37.00
Pursuant to UCA § 48-3a-1055 causes this Statement of Domestication to be delivered to the Utah Division of
Corporations for filing, and states as follows:
1. The Statement of Domestication shall state:
Entity Number: _____________________________________
First: The name and entity type of the company immediately prior to the filing of the articles of
domestication:
Name: _______________________________________________________________________________
Entity Type (Corp, LLC, LP, Partnership, DBA, etc.): ________________________________
Second: The date and state where the company was first created and, if it has changed, its jurisdiction
immediately prior to its domestication:
_______________________________ _______________________________
Date of formation State / Jurisdiction
Third: The name and entity type of the company as set forth in its domesticated entity filing;
Name: _______________________________________________________________________________
Entity Type: ________________________________ _______________________________
State / Jurisdiction
______________________________________________________________________________________
Registered Agent address or mailing address for service of process if not qualified as a foreign entity in Utah
Fourth: The plan of domestication was approved in accordance with Utah law or, if a foreign entity, the
law of the jurisdiction of its formation;
Fifth: The future effective date of the domestication to the new entity if it is not to be effective upon the
filing of the statement of domestication:
__________________00''<<<<
Sixth: Under penalties of perjury, I declare that the statement of domestication have been duly approved
by the owners of the entity.
Name: ______________________________ Signature: ___________________________
Title:_______________________________ Date: _______________________________
2. Additional filing requirements: The non-refundable processing fee of $37.00 payable to the State of Utah,
and application for new
entity must accompany this form. No additional fee for the new application.
Under GRAMA {63G-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you
may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity.
State of Utah
Department of Commerce
Division of Corporations & Commercial Code
Statement of Domestication
This form must be type written or computer generated.
Sign here after the form is printed
Mailing/Faxing Information:
www.corporations.utah.gov/contactus.html
www.corporations.utah.gov
