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PENNSYLVANIA DEPARTMENT OF STATE 
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS       

      Return document by mail to:                                                              
                                                                                                     Statement of Withdrawal  
                                                                                                     of Foreign Registration 
 Name                                                                                                 DSCB:15-415/417 
                                                                                                                                                                                                                         
                                                                                                      (7/1/2015) 
 Address 
  
 City                                              State                             Zip Code        *4157*
                                                                                                                            
                                                                                                      4157 
      Return document by email to: _________________________________ 
 
      Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/.  
 
Fee:  $70 
 
      Check One:        Voluntary Withdrawal of Foreign Registration                                 Required Withdrawal of Foreign Registration 
                   (complete fields 1-5)                                                            (complete fields 1-6) 
 
              In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 415 or § 417 (relating to 
withdrawal of foreign registration), the undersigned registered foreign association hereby states that: 
 
1. The name of the association under which it is registered to do business in this Commonwealth is: 
 
2.  The jurisdiction of formation of the association is: _______________________________________________________ 
 
3.  The (a) address of the association’s 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 
                                                                                              OR 
                                                                                               
(b) c/o: _____________________________________________________________________________________________________ 
              Name of Commercial Registered Office Provider                                                                                       County 
 
4. The association is not doing business in this Commonwealth and withdraws its registration to do business in this 
Commonwealth. 
 
5.  This Statement of Withdrawal of Foreign Registration shall take effect upon filing in the Department of State.

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  DSCB:15-415/417– 2 
   
  For REQUIRED WITHDRAWAL ONLY 
   
  6.Check and,if appropriate complete, one of the following.   The registered foreign association is: 
    A nonsurviving party to a merger in which the survivor is a nonregistered foreign association. 
    A dividing association which did not survive the division. 
    Dissolved and completed winding up.  
    Converted to a domestic or foreign nonfiling association other than a limited liability partnership.  
    The type of nonfiling association to which the association has converted is:_________________________________ 
    and the jurisdiction of formation of the converted association is: _________________________________________.  
    The domesticating entity in a domestication in which the domesticated entity is a domestic or foreign nonfiling 
    association (other than a limited liability partnership).  
    The jurisdiction of formation of the domesticated association is: ________________________________________. 
   
  IN TESTIMONY WHEREOF, the undersigned foreign association has caused this Statement of Withdrawal of Foreign 
  Registration to be signed by a duly authorized representative of the association this __________ day of  
  _________________________20_____       . 
   
                                                               ______________________________________ 
                                                                                   Name of Foreign Association 
   
                                                               ___________________________________________________ 
                                                                                             S ig n a tu r e  
   
                                                               ___________________________________________________ 
                                                                                                Title

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DSCB:15-415/417–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
Typewritten is preferred. If handwritten, the form must be Tax clearance certificates:
legible and completed in black or blue-black ink in order to A registered foreign association may not file a Statement of
permit reproduction. Withdrawal of Foreign Registration unless the document is
accompanied by tax clearance certificates from the
The nonrefundable filing fee for this form is $70. Checks Department of Revenue and the Department of Labor and
should be made payable to the Department of State. Checks Industry evidencing the payment by the association of all taxes
must contain a commercially pre-printed name and address. and charges due the Commonwealth required by law. To
obtain these clearance certificates, Form REV-181
This form and all accompanying documents shall be mailed to (Application for Tax Clearance Certificate) must be completed
the address stated above. and submitted to both the Department of Revenue and the
Department of Labor and Industry. The application and
Who should file this form? instructions may be downloaded from the Department of
A registered foreign association may withdraw from Revenue website at www.revenue.pa.gov or obtained by
transacting business or conducting affairs in the calling 717-783-6052.
Commonwealth of Pennsylvania by delivering to the
Department of State for filing a Statement of Withdrawal of Advertising:
Registration. As required by 15 Pa.C.S. § 4129 or by 15 Pa.C.S. § 6129
(relating to Advertisement of termination of registration to do
A Statement of Withdrawal will serve to remove the business), a corporation must advertise its intention to
association from the rolls of active associations in the records withdraw from doing business in Pennsylvania before filing a
of the Department. Statement of Withdrawal under section 415 (relating to
voluntary withdrawal of registration). Proofs of publication of
Withdrawal is either voluntary or may be required in certain such advertising should not be submitted to, and will not be
circumstances. Those required circumstances are when the received by or filed in, the Department, but should be filed
registered foreign association is: with the minutes of the corporation.
(1) a nonsurviving party to a merger in which the survivor
is a nonregistered foreign association; Form Instructions
(2) a dividing association which did not survive the Enter the name and mailing address to which any
division; correspondence regarding this filing should be sent. This field
(3) dissolved and completed winding up; must be completed for the Bureau to return the filing. If the
(4) converted to a domestic or foreign nonfiling association filing is to be returned by email, an email address must be
other than a limited liability partnership; or provided. An email will be sent to address provided,
(5) the domesticating entity in a domestication in which the containing a link and instructions on how a copy of the filed
domesticated entity is a domestic or foreign nonfiling document or correspondence may be downloaded. Any email
association other than a limited liability partnership. or mailing addresses provided on this form will become part
of the filed document and therefore public record.
Applicable Law
For foreign associations, in general, 15 Pa.C.S. §§ 102; 401- 1. Give the exact name of the association as registered to do
419; for withdrawal of registration, 15 Pa.C.S. §§ 415-417. business in Pennsylvania and as on file with the Department of
Statutes are available on the Pennsylvania General Assembly State.If a foreign association has adopted an alternate name in
website, www.legis.state.pa.us, by following the link for order to register to do business in Pennsylvania, the registered
Statutes. foreign association must use the alternate name in response to
a requirement that a document delivered to the Department for
Attachments filing state the name of the association. This field is required.
The following, in addition to the filing fee, shall accompany
this form: 2. “Jurisdiction of formation” means the jurisdiction, other
(1) Tax clearance certificates from the Department of
than Pennsylvania, whose law includes the governing statute
Revenue and the Department of Labor and Industry of the withdrawing association. This field is required.
evidencing payment of all taxes and charges payable to
the Commonwealth as described in the following 3. Give one of the following: the current registered office
paragraph. address in the Commonwealth in (a) or the name of a
(2) Any necessary governmental approvals.

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DSCB:15-415/417–Instructions 
 
Commercial Registered Office Provider (b) and the county of 
venue, as on file with the Department of State.   
 
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.  
 
4.  Mandatory statement. This field is required. 
 
5.  Mandatory statement. No delayed effective date may be 
specified per 15 Pa.C.S. § 415(b).  This field is required. 
 
6.This field is required only if the withdrawal is required 
by law due to one of the following: 
The registered foreign association is:  
  (1)  a nonsurviving party to a merger in which the survivor 
is a nonregistered foreign association; 
  (2)  a dividing association which did not survive the 
division; 
  (3)  dissolved and completed winding up; 
  (4)  converted to a domestic or foreign nonfiling association 
other than a limited liability partnership; or 
  (5)  the domesticating entity in a domestication in which the 
domesticated entity is a domestic or foreign nonfiling 
association other than a limited liability partnership. 
 
Check only one of the five boxes and complete all blanks in 
the associated text. 
 
Signature and Verification 
An authorized representative of the withdrawing, surviving or 
converted foreign association must sign the Statement of 
Withdrawal. 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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