Non-Refundable Processing Fee: $37.00
1. The Articles/Statement of Conversion shall state:
Entity Number: _____________________________________
First: The name and entity type of the company immediately prior to the filing of the conversion:
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 conversion;
_______________________________ _______________________________
Date of formation State / Jurisdiction
Third: The name and entity type of the company as set forth in its converted 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 future effective date of the conversion to the new entity if it is not to be effective upon the
filing of the conversion;
___________________00''<<<<
Fifth: Under penalties of perjury, I declare that the Articles/Statement of Conversion 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
Articles/Statement of Conversion
This form cannot be hand written.
Sign here after the form is printed
Mailing/Faxing Information:
www.corporations.utah.gov/contactus.html
www.corporations.utah.gov
