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PENNSYLVANIA DEPARTMENT OF STATE 
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS      Return document by mail to: 

Name 

Address 

City                                                State                             Zip Code 

 Return document by email to: _________________________________
 
  Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/.  

  Fee:  $125                                        I qualify for a veteran/reservist-owned small business fee exemption (see instructions) 

             In compliance with the requirements of 15 Pa.C.S. § 8821 (relating to certificate of organization), the 
  undersigned desiring to organize a limited liability company, hereby certifies that: 

  1.    The name of the limited liability company is: ___________________________________________________
        (designator is required, e.g., “company,” “limited” or “limited liability company” or any abbreviation thereof)

  2.    Complete part (a) or (b) – not both:
        (a) The address of this limited liability company’s registered office in this Commonwealth is:
             (post office box alone is not acceptable)

        Number and Street                                City                                   State                    Zip       County 

        (b) The name of this limited liability company’s commercial registered office provider and county of venue
        is:
        c/o: 
        Name of Commercial Registered Office Provider                                             County 

  3.    The name of each organizer is (all organizers must sign on page 2):

  4.    Effective date of Certificate of Organization (check, and if appropriate complete, one of the following):
           The Certificate of Organization shall be effective upon filing in the Department of State. 
           The Certificate of Organization shall be effective on: ________________________ at ______________. 
                                                                                                 Date (MM/DD/YYYY)    Hour (if any) 



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DSCB:15-8821-2 

5. Restricted professional companies only.
   Check the box if the limited liability company is organized to render a restricted professional service and
   check the type of restricted professional service(s).
   The company is a restricted professional company organized to render the following restricted 
   professional service(s): 
   Chiropractic 
   Dentistry 
   Law 
   Medicine and surgery 
   Optometry 
   Osteopathic medicine and surgery 
   Podiatric medicine 
   Public accounting 
   Psychology 
   Veterinary medicine 

6. Benefit companies only.
   Check the box immediately below if the limited liability company is organized as a benefit company:
   This limited liability company shall have the purpose of creating general public benefit. 

   Optional specific public benefit purpose. Check the box immediately below if the benefit company is 
   organized to have one or more specific public benefits and supply the specific public benefit(s).  
   See instructions for examples of specific public benefit.  
   This limited liability company shall have the purpose of creating the enumerated specific public 
   benefit(s):   

7. For additional provisions of the certificate, if any, attach 8½ x 11 sheet(s).

IN TESTIMONY WHEREOF, the organizer(s) has (have) executed this Certificate of Organization this 

 __________ day of _____________________________, 20               . 

                                             ______________________________________________________________ 
                                                                                 Signature 

                                             ______________________________________________________________ 
                                                                                 Signature 

                                             ______________________________________________________________ 
                                                                                 Signature 



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DSCB:15-8821–Instructions 

                                           Pennsylvania Department of State 
                              Bureau of Corporations and Charitable Organizations 
                                                             P.O. Box 8722 
                                               Harrisburg, PA  17105-8722 
                                                             (717) 787-1057
                                               Website: www.dos.pa.gov/corps 

General Information                                              Restricted words and/or approvals: 
Typewritten is preferred.  If handwritten, the form must be      Association names may not contain words, phrases or 
legible and completed in black or blue-black ink in order to     abbreviations prohibited or restricted by statute or regulation, 
permit reproduction.                                             unless in compliance with the restriction, generally with the 
                                                                 consent or approval of a government agency, board or 
The nonrefundable filing fee for this form is $125. Checks       commission.  These may include certain professional and 
should be made payable to the Department of State.  Checks       occupational boards or commissions of the Bureau of 
must contain a commercially pre-printed name and address.        Professional and Occupational Affairs, the Department of 
Filers requesting a veteran/reservist-owned small business fee   Education, the Department of Banking and Securities, the 
exemption should attach proof of the veteran’s or reservist’s    Insurance Department or the Public Utility Commission. 
status to the Certificate of Organization form when submitted.   There are also words and abbreviations that may be restricted, 
For more information on the fee exemption, see Fees and          prohibited, or may be permitted in certain instances as 
Payments.                                                        provided in various federal statutes, Attorney General 
                                                                 opinions and Bureau regulations. 
This form and all accompanying documents shall be mailed to 
the address stated above.                                        Attachments 
                                                                 The following, in addition to the filing fee, shall accompany 
Who should file this form?                                       this form: 
One or more persons acting as organizers to form a limited                 (1) One copy of a completed form 
liability company must file a certificate of organization in the DSCB:15-134A (Docketing Statement). 
Department of State.                                                       (2) Any necessary copies of form DSCB:19-17.2 
                                                                 (Consent to Appropriation of Name). 
Applicable Law                                                             (3) Any necessary governmental approvals.
See 15 Pa.C.S. § 8821 for general information on Formation 
of Limited Liability Company and Certificate of Organization.    Form Instructions 
Statutes are available on the Pennsylvania General Assembly      Enter the name and mailing address to which any 
website, www.legis.state.pa.us, by following the link for        correspondence regarding this filing should be sent.  This field 
Statutes. See also 15 Pa.C.S. § 8898 and § 8998 for provisions   must be completed for the Bureau to return the filing. If the 
on annual reports/registrations that are required of benefit     filing is to be returned by email, an email address must be 
companies and restricted professional companies, respectively.   provided. An email will be sent to address provided, 
                                                                 containing a link and instructions on how a copy of the filed 
Limited Liability Company Name Requirements                      document or correspondence may be downloaded. Any email 
Generally, the name of an association may not be the same as     or mailing addresses provided on this form will become part 
the name of another association which is already on the          of the filed document and therefore public record. 
records of the Department of State. Depending on the type of 
association, certain designators must be used in the association 1. Give the exact name of the limited liability company.
name. Designators are the words or abbreviations used at the     This should include the exact spelling, punctuation and a
end of the association name which designate the type of          permissible designator. This field is required.
association. The minimum requirements for limited liability 
company names can be found at 15 Pa.C.S. §§ 201, 202 and         2. Address. This address must be in Pennsylvania. Give one of
204.                                                             the following:  the registered office address in the
                                                                 Commonwealth in (a) or the name of a Commercial
The name of a domestic limited liability company must            Registered Office Provider in (b) and the county of venue.
contain: 
(1) the term “company,” “limited” or “limited liability          Listing a Commercial Registered Office Provider in lieu of 
comp any” or an abbreviation of one of those terms, or           providing a registered office address is an option for any 
(2) words or abbreviations of like import used in a              association that does not have a physical location or mailing 
jurisdiction other than this Commonwealth.                       address in Pennsylvania. Prior to listing a Commercial 
The name of a limited liability company may not contain any      Registered Office Provider address, the association should 
words implying that it is a business corporation, such as        enter into a contract for the services of the Commercial 
“corporation” or “incorporated” or an abbreviation of these      Registered Office Provider. 
terms. 



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Post office boxes are not acceptable for any address. Under 15     its purpose under 15 Pa.C.S. § 8818(b). “Specific public 
Pa.C.S. § 135(c) (relating to addresses), an actual street or      benefit” includes: 
rural route box number must be used as an address, and the          
Department of State is required to refuse to receive or file any     (1) providing low-income or underserved individuals or 
document that sets forth only a post office box address.           communities with beneficial products or services; 
This field is required.                                              (2) promoting economic opportunity for individuals or 
                                                                   communities beyond the creation of jobs in the normal course 
3.  An organizer is a person that acts to form a limited liability of business; 
company. “Person” is defined to include a corporation,               (3) preserving the environment; 
partnership, limited liability company, business trust, other        (4) improving human health; 
association, government entity (other than the                       (5) promoting the arts, sciences or advancement of 
Commonwealth), estate, trust, foundation or natural person.        knowledge; 
When the limited liability company has more than three               (6) promoting economic development through support of 
organizers, additional lines should be added as appropriate.       initiatives that increase access to capital for emerging and 
This field is required.                                            growing technology enterprises, facilitate the transfer and 
                                                                   commercial adoption of new technologies, provide technical 
4.  Effective date. Any date specified as the effective date of    and business support to emerging and growing technology 
the Certificate of Organization must be a future effective date    enterprises or form support partnerships that support those 
(after the date and time of its delivery to the Department). A     objectives; 
specified effective date may not be retroactive (prior to the        (7) increasing the flow of capital to entities with a public 
date and time of the Certificate’s delivery to the Department).    benefit purpose; and 
If a delayed effective date is specified, but no time is given,      (8) the accomplishment of any other particular benefit for 
then the time used will be 12:01 a.m. on the date specified.       society or the environment. 
If no effective date is provided, it will be presumed that no       
specified delayed effective date is intended and the document      Note that benefit companies must file annual benefit reports in 
will be effective upon filing. This field is required.             accordance with 15 Pa.C.S. § 8898.  
                                                                    
5.  Restricted professional services are identified as the         If the limited liability company is organized as a benefit 
following professional services: chiropractic, dentistry, law,     company, the box before the statement “This limited liability 
medicine and surgery, optometry, osteopathic medicine and          company shall have the purpose of creating general public 
surgery, podiatric medicine, public accounting, psychology or      benefit” should be checked. If the limited liability company is 
veterinary medicine. If the limited liability company is           organized as a benefit company, a specific public benefit 
organized to render any of the identified restricted               purpose is optional. If the box before the statement “This 
professional services, the box before the statement “The           limited liability company shall have the purpose of creating 
company is a restricted professional company organized to          the enumerated specific public benefit(s)” is checked, one or 
render the following restricted professional service(s)” must      more specific public benefits must be listed. If the limited 
be checked and the appropriate restricted professional             liability company is not organized as a benefit company, do 
service(s) must be checked. If the limited liability company is    not check any of the boxes or list any specific public benefits. 
not organized to render any of the identified restricted            
professional services, do not check the box or list a profession.  7. Additional provisions. A certificate of organization may 
                                                                   contain statements as to matters other than those required by 
Note that restricted professional companies must file              15 Pa.C.S. § 8821(b), but may not vary or otherwise affect the 
certificates of annual registration and pay annual registration    provisions specified under § 8815(c) and (d) (relating to 
fees in accordance with 15 Pa.C.S. § 8998.                         contents of operating agreement) in a manner inconsistent 
                                                                   with that section. 
6.  A benefit company shall be formed in accordance with 15         
Pa.C.S. § 8821, except that its certificate of organization shall  Signature and Verification 
also state that it is a benefit company.                           All organizers must sign the Certificate of Organization. If an 
                                                                   organizer is not a natural person, an authorized representative 
A benefit company shall have a purpose of creating general         of the organizing association must sign the Certificate.  
public benefit. A “general public benefit” is defined as a         When the limited liability company has more than three 
material positive impact on society and the environment, taken     executing organizers, additional signature lines should be 
as a whole and assessed against a third-party standard, from       added as appropriate. Signing a document delivered to the 
the business and operations of a benefit company. This             Department for filing is an affirmation under the penalties 
purpose is in addition to its purpose under 15 Pa.C.S. §           provided in 18 Pa.C.S. § 4904 (relating to unsworn 
8818(b).                                                           falsification to authorities) that the facts stated in the 
                                                                   document are true in all material respects. This field is 
The certificate of organization of a benefit company may           required. 
identify one or more specific public benefits that it is the 
purpose of the benefit company to create in addition to its 
general public benefit purpose under 15 Pa.C.S. § 8894(a) and 






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