Form Dscb:15-134b - Docketing Statement (Changes) Page 2
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1
2Section C - Consolidation
Consolidating Entities are: (attach sheet for additional consolidating entities)
Name:
Entity #, if known:
Inc./qual. date in PA.
State of Inc.
Name:
Entity #, if known:
Inc./qual. date in PA.
State of Inc.
Section D – Division
Forming new entity(s) named below: (attached sheet for additional entities)
Name:
Entity Number:
Name:
Entity Number:
Check one:
Entity named in Part I survives. (any changes, complete Section A)
Entity named in Part I does not survive.
Section E – Conversion (complete Section A)
Check one:
Converted from nonprofit to profit
Converted from profit to nonprofit
Section F –
Dissolved by Shareholders or Incorporators Before Commencement of Business
Section G – Statement of Revival (complete Section A for any changes to revived entity)
Entity named in Part I hereby revives its charter or articles which were forfeited by Proclamation or expired.
Section H – Statement of Termination
(attach sheet for additional entities involved)
filed in the Department of State on
is/are hereby terminated.
(type of filing made)
month/date/year hour, if any
If merger, consolidation or division, list all entities involved, other than that listed in Part I:
Name:
Entity number:
Name:
Entity number:
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