Form Dscb:15-355 - Statement Of Conversion Page 3
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4. Check and complete one of the following addresses for the converted association.
If the converted association is a domestic filing association, domestic limited liability partnership or
registered foreign association, its registered office address. Complete part (a) OR (b) – not both:
(a) _________________________________________________________________________________________________
Number and street
City
State
Zip
County
(b) c/o: ______________________________________________________________________________________________
Name of Commercial Registered Office Provider
County
If the converted association is a domestic association that is not a domestic filing association or limited
liability partnership, the address, including street and number, if any, of its principal office:
____________________________________________________________________________________________________
Number and street
City
State
Zip
County
If the converted association is a nonregistered foreign association, complete both (1) and (2).
(1) The address, including street and number, if any, of its registered or similar office, if any, required to be
maintained by the law of its jurisdiction of formation; or if it is not required to maintain a registered or similar
office, its principal office address:
____________________________________________________________________________________________________
Number and street
City
State
Zip
(2) The name and address, including street and number, of its registered agent:
____________________________________________________________________________________________________
Name of Registered Agent
____________________________________________________________________________________________________
Number and street
City
State
Zip
C. Effective date of statement of conversion (check, and if appropriate complete, one of the following):
This Statement of Conversion shall be effective upon filing in the Department of State.
This Statement of Conversion shall be effective on: _________________________ at __________________.
Date (MM/DD/YYYY)
Hour (if any)
D. Approval of conversion by converting association (check only one):
For converting association that is a domestic entity – The plan of conversion was approved in accordance with 15
Pa.C.S. Chapter 3, Subchapter E (relating to conversion).
For converting association that is a foreign association – The conversion was approved in accordance with the law
of the jurisdiction of formation of the converting association.
E. Attachments (see Instructions for required and optional attachments).
IN TESTIMONY WHEREOF, the undersigned converting association has caused this Statement of Conversion to be
signed by a duly authorized officer thereof this ______________ day of ____________________________, 20_______.
___________________________________________________
Name of Converting Association
___________________________________________________
Signature
___________________________________________________
Title
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