PENNSYLVANIA DEPARTMENT OF STATE 
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS       
                                                                                                                   
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                                                                                                      Annual Statement - Nonprofit Corporation 
  
                                                                                                        DSCB:15-5110  
 Name                                                                                                   (rev. 7/2015) 
                                                                                                                                                                                                                              
 Address 
  
 City                                             State                             Zip Code            *5110*  
  
                                                                                                              5110 
      Return document by email to: _________________________________ 
 
      Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/.  
 
Fee:  None 
 
           In compliance with the requirements of 15 Pa.C.S. § 5110 (relating to annual report), the undersigned domestic or 
qualified foreign nonprofit corporation, hereby states that: 
 
      1. The name of the corporation is: 
       
      2.  The address of its principal office is:  
       
             Number and street                                   City                           State                  Zip                County 
 
      3.  The names and title of the persons who are its principal officers are: 
            Names                                                                              Titles 
       
                                                   IN TESTIMONY WHEREOF, the undersigned corporation 
 
                                                   has caused this Annual Statement to be signed by a duly 
                                                   authorized officer thereof this   
                                                    
                                                                day of                                       ,                          . 
                                                    
                                                   _____________________________________________________ 
                                                                                                        Name of Corporation 
                                                    
                                                                                                        Signature 
                                                                                                         
                                                                                             _________________________________________________ 
                                                                                                        Title 

DSCB:15-5110–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 
 
Instructions for Completion of Form: 
 
A.  Typewritten is preferred.  If handwritten, the form shall be legible and completed in black or blue-black ink in order to 
 permit reproduction.  There is no filing fee with respect to this form. 
 
 Enter the name and mailing address to which any correspondence regarding this filing should be sent.  This field must be 
 completed for the Bureau to return the filing. If the filing is to be returned by email, an email address must be provided. An 
 email will be sent to address provided, containing a link and instructions on how a copy of the filed document or 
 correspondence may be downloaded. Any email or mailing addresses provided on this form will become part of the filed 
 document and therefore public record. 
 
B.  On or before April 30 of each year where there has been a change in corporate officers during the preceding calendar 
 year, this form shall be filed by each domestic nonprofit corporation which effected any filing in the Department of 
 State after December 31, 1972 and by each registered foreign nonprofit corporation.   
 
C.   This form is not a substitute for form DSCB:15-1507/5507/8506/8906 (Statement of Change of Registered Office), 
 and the appropriate form shall be filed to reflect a change in Pennsylvania registered office address. 
 
D.  This form and all accompanying documents shall be mailed to the above stated address.