PENNSYLVANIA DEPARTMENT OF STATE 
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS 
                      
             Docketing Statement – Changes 
  DSCB:15-134B 
  (rev. 7/1/2015) 
 
  BUREAU USE ONLY:  
  Revenue ____      Labor & Industry ____      Other _________________________      Filed Date ________________                                  
 
Part I.  Complete for each filing: 
Current name of entity or association (survivor or new entity): 
 
 Entity number, if known: __________________          Formation/foreign registration date in PA: __________________ 
 
State of formation: ________________________          Effective date, if any: ________________________ 
 
Part II.  Check appropriate transaction: 
         ____ Amendment (complete Section A)                               ____ Correction (complete Section A) 
         ____ Merger (complete Section B)                                  ____ Division (complete Section C) 
         ____ Conversion (complete Sections A and D)                       ____ Abandonment (complete Section E) 
         ____ Revival (complete Section F)                                 ____ Domestication (complete Section G)                               
         ____ Dissolution before Commencement of Business  
           (complete Section H) 
 
Section A – Amendment or Correction - Complete fields which pertain to changes: 
 
Name_____________________________________________________________________________________________ 
 
Registered Office: __________________________________________________________________________________ 
                         Number and street                   City                                  State               Zip               County 
 
Purpose ___________________________________________________________________________________________ 
 
Stock (aggregate number of shares authorized): __________________              Effective Date: ___________________ 
 
Term of Existence: _______________________                      O th e r : ________________________________________ 
 
Filing type to be amended or corrected: _____________________________________________ 
 
Section B – Merger - Complete Section A with any changes to the association surviving the merger, if any 
     Merging entities not surviving the merger are:  (attach sheet for additional merging entities) 
 
___________________________________________________________________________________________________________ 
Name 
 
____________________________________________________________________________________________________________ 
Effective Date    Incorporation/foreign registration date in PA                                     State of Jurisdiction 
 
___________________________________________________________________________________________________________ 
Name 
 
____________________________________________________________________________________________________________ 
Effective Date    Incorporation/ foreign registration date in PA                                    State of Jurisdiction 

DSCB:15-134B-2       
 
Section C – Division - Complete Section A with any changes to the association surviving the division, if any 
 
Check only one:      ____ Entity named in Part I survives              ___ Entity named in Part I does not survive. 
     
Newly created entity(s) from the division are: (attach sheet for additional new entities) 
 
___________________________________________________________________________________________________________ 
N a m e                                                                                         E n tity  N u m b e r  
 
___________________________________________________________________________________________________________ 
N a m e                                                                                         E n tity  N u m b e r  
 
Section D – Conversion 
Type of converting association (check only one):           Type of converted association (check only one): 
___ Business Corporation                                    ___ Business Corporation 
___ Nonprofit Corporation                                   ___ Nonprofit Corporation 
___ General Partnership      ___ General Partnership 
___ Limited Partnership      ___ Limited Partnership 
___ Limited Liability (General) Partnership                 ___ Limited Liability (General) Partnership 
___ Limited Liability Limited Partnership                   ___ Limited Liability Limited Partnership 
___ Limited Liability Company                               ___ Limited Liability Company 
___ Professional Association      ___ Professional Association 
___ Business Trust/Common Law Trust/Statutory Trust         ___ Business Trust/Common Law Trust/Statutory Trust 
___ Other _____________________________________             ___ Other ____________________________________ 
 
Jurisdiction ___________________________________            Jurisdiction ___________________________________ 
 
Section E – Abandonment  
___________________________________________________         filed in the Department of State on ____________________________ 
                               Type of filing                                                   Date of filing 
     
 Identify all entities involved (attach sheet for additional entities) 
 
___________________________________________________________________________________________________________ 
N a m e                                                                                         E n tity  N u m b e r  
 
___________________________________________________________________________________________________________ 
N a m e                                                                                         E n tity  N u m b e r  
 
Section F – Revival - complete Section A with any changes to revived association 
___ Entity named in Part I hereby revives its charter or articles which were forfeited by Proclamation or expired. 
 
Section G – Domestication 
Domesticating jurisdiction ___________________________ Domesticated jurisdiction ________________________ 
                                                           Check if applicable 
                                                           ___ Domesticated entity is a nonregistered foreign 
                                                                       association 
 
Section H – Dissolution before Commencement of Business  
___ Entity named in Part I hereby dissolves prior to the commencement of business.