PENNSYLVANIA DEPARTMENT OF STATE
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
Return document by mail to:
Statement of Conversion
DSCB:15-355
Name
(7/1/2015)
Address
*355*
City
State
Zip Code
355
Return document by email to:
_________________________________
Fee: $70
In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 355 (relating to Statement of
conversion), the undersigned association, desiring to effect a conversion, hereby states that:
A. For the converting association:
1. The name of the converting association is: _________________________________________________________
2. The jurisdiction of formation of the converting association is: __________________________________________
3. The type of association is (check only one):
Business Corporation
Limited Partnership
Business Trust
Nonprofit Corporation
Limited Liability (General) Partnership
Professional Association
Limited Liability Company
Limited Liability Limited Partnership
Other ____________________
4. Date on which the association was created, incorporated, formed or otherwise came into existence:
_______________________________________________
(MM/DD/YYYY)
5. If the converting association is a domestic filing association (a Pennsylvania business corporation, nonprofit
corporation, limited partnership, limited liability company, professional association or business trust), the statute
under which it was first created, incorporated, formed or otherwise came into existence:
________________________________________________
(ex. Business Corporation Law of 1988, Limited Liability Company Law of 1994, etc.)