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  PENNSYLVANIA DEPARTMENT OF STATE 
  BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS       
         Return document by mail to:                                                                                           
                                                                                                        Statement of Domestication - Other 
     
                                                                                                                          DSCB:15-161 
    Name 
                                                                                                                                                                                                                               (7/1/2015) 
    Address                                                                                                                    
     
    City                                                  State                             Zip Code        *161*  
     
                                                                                                                           161 
         Return document by email to: _________________________________ 
   
                                                          Read all instructions prior to completing. 
  Fee:  $70 
   
             In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 161 (relating to domestication of 
  certain alien associations), the undersigned association, desiring to become a domestic association, hereby states that: 
   
  1.  The name of the association is:  _____________________________________________________________________ 
   
  2.  The date on which the association was first formed, incorporated or otherwise came into being is: _________________ 
   
  3.  The name of the jurisdiction under the laws of which it was first formed, incorporated or otherwise came into being is: 
   
  4.  The name of the jurisdiction that constituted the seat, siege social or principal place of business or control 
     administration of the entity, or any equivalent under applicable law, immediately prior to the filing of this statement is: 
   
  5.  Upon domestication, the association will be a domestic association under the laws of the Commonwealth of 
  Pennsylvania.  Specify type of association: _______________________________________________________________ 
    
   6.  The (a) address of the association’s proposed registered office in this Commonwealth or (b) name of its commercial 
     registered office provider and the county of venue is:  Complete part (a) OR (b) – not both: 
      
     (a)  _____________________________________________________________________________________________________       
                Number and street                                                City                                       State                   Zip                  County 
       
     (b) c/o: __________________________________________________________________________________________________ 
                   Name of Commercial Registered Office Provider                                                                                              County 
   
  7.  The filing of this statement has been authorized by a majority in interest of the interest holders of the association or by 
     any greater vote required by its organic rules. 
   
  8.  Optional statement – please check box if applicable.         
         The renunciation of the prior domicile of the undersigned association has been authorized by a majority in interest 
         of the interest holders of the association or by any greater vote required by its organic rules. 
   
  IN TESTIMONY WHEREOF, the undersigned association has caused this Statement of Domestication - Other to be 
  signed by a duly authorized officer thereof this ______________ day of  ____________________________ 20_______. 
   
                                                                                                       ______________________________________ 
                                                                                                                          Name of Association 
   
                                                                                                       ______________________________________ 
                                                                                                                      S ig n a tu r e  
  
                                                                                                       ______________________________________ 
                                                                                                                        Title 



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DSCB:15-161 - Instructions 
                                                                  
                                            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 
 
General Information                                               characters or Arabic or Roman numerals. If the name is one 
Typewritten is preferred.  If handwritten, the form must be       that is rendered unavailable for use by a domestic entity by 
legible and completed in black or blue-black ink in order to      section 202(b) or (c) (relating to requirements for names 
permit reproduction.                                              generally), the association shall adopt a new name, in 
                                                                  accordance with any procedures for changing the name of the 
The nonrefundable filing fee for this form is $70. Checks         association that are applicable prior to the domestication of the 
should be made payable to the Department of State.  Checks        association, and shall set forth the new name in the statement. 
must contain a commercially pre-printed name and address.         It is not intended that the association must formally change its 
                                                                  name prior to domesticating since there would be no reason 
This form and all accompanying documents shall be mailed to       for Pennsylvania to require a filing in the jurisdiction that the 
the address stated above.                                         association is leaving. Rather, it will be sufficient for the 
                                                                  association to obtain whatever approvals by the interest 
Applicable Law                                                    holders of the association and those persons managing its 
See 15 Pa.C.S. § 161 for general information on                   affairs would be necessary to change its name. This field is 
Domestication of Certain Alien Associations. Statutes are         required. 
available on the Pennsylvania General Assembly website,            
www.legis.state.pa.us, by following the link for Statutes.        2. Give the date on which the domesticating entity was 
                                                                  originally incorporated or formed. Provide month, day and 
Who should file this form?                                        year. This field is required. 
This form sets forth a procedure by which an association that      
is organized under the laws of a jurisdiction other than          3.  Give the jurisdiction of formation of the domesticating 
Pennsylvania and that is not an “entity” (and thus is not         entity. This must be a jurisdiction other than Pennsylvania and 
eligible to domesticate in Pennsylvania under Subchapter G or     will most likely be a jurisdiction outside of the United States 
Chapter 3) may become a domestic Pennsylvania association.        and its territories. For example, if the domesticating 
                                                                  association was originally chartered, formed or organized in 
An association that can be domesticated under Subchapter G        the Republic of Uzbekistan, then the jurisdiction of formation 
of Chapter 3 (relating to domestication) must use DSCB:15-        is Uzbekistan. This field is required. 
375 (Statement of Domestication) and may not be                    
domesticated using this form [DSCB:15-161 (Statement of           4.  Give the jurisdiction which constituted the principal place 
Domestication – Other)].                                          of business for the domesticating entity immediately prior to 
                                                                  the domestication. This must be a jurisdiction other than 
Attachments                                                       Pennsylvania and will most likely be a jurisdiction outside of 
The following, in addition to the filing fee, shall               the United States and its territories. For example, if the 
accompany this form:                                              domesticating association was had its principal place of 
  (1)  One copy of a completed form DSCB:15-134A                  business or control in the Federative Republic of Brazil 
(Docketing Statement).                                            immediately prior to the domestication, then the jurisdiction 
                                                                  constituting the seat or control of the association is Brazil. 
                                                                  This field is required. 
                                                                   
Form Instructions                                                 5.  Fill in the type of Pennsylvania association that the 
Enter the name and mailing address to which any                   domesticating association will become upon domestication. 
correspondence regarding this filing should be sent.  This field  Types of domestic associations include: business corporation, 
must be completed for the Bureau to return the filing. If the     nonprofit corporation, limited liability company, limited 
filing is to be returned by email, an email address must be       partnership, limited liability (general) partnership, limited 
provided. An email will be sent to address provided,              liability limited partnership, professional association or 
containing a link and instructions on how a copy of the filed     business trust. 
document or correspondence may be downloaded. Any email            
or mailing addresses provided on this form will become part       Since this form is designed particularly for associations that do 
of the filed document and therefore public record.                not correspond directly to a recognized type of Pennsylvania 
This form shall be executed in the English language.              association, this field leaves to the domesticating association 
                                                                  the choice of the type of association it will be under 
1.  Give the exact name of the association. If the name is in a   Pennsylvania law. This field is required. 
foreign language, it shall be set forth in Roman letters or        



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DSCB:15-161 - Instructions 
 
6.  This address must be in Pennsylvania. Give one of the 
following:  the registered office address in the Commonwealth 
in (a) or the name of a Commercial Registered Office Provider 
(b) and the county of venue.   
 
Listing a Commercial Registered Office Provider in lieu of 
providing a registered office address is an option for any 
association that does not have a physical location or mailing 
address in Pennsylvania. Prior to listing a Commercial 
Registered Office Provider address, the association should 
enter into a contract for the services of the Commercial 
Registered Office Provider. 
 
Post office boxes are not acceptable for any address. 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.  
This field is required. 
 
7.  This is a required statement. 
 
8.  Check box if statement is applicable.  This field is 
optional. 
 
Signature and Verification 
An authorized representative of the domesticating entity must 
sign the Statement of Domestication - Other. Signing a 
document delivered to the Department for filing is an 
affirmation under the penalties provided in 18 Pa.C.S. § 4904 
(relating to unsworn falsification to authorities) that the facts 
stated in the document are true in all material respects. This 
field is required. 
 






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