Form 800 - Certificate Of Conversion 2008 Page 2
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1
2Effective Date (Optional)
This conversion is effective on _________________
(If a date is specified, the date must be a date
on or after the date of the filing. If no date is specified, the date of filing will be the effective date of the conversion).
if no date is specified, the date of filing will be the effective date of the conversion).
The name and address of the person or entity that will provide a copy of the declaration of conversion
upon written request
Name
Mailing Address
City
State
Zip Code
If the conversion creates a new domestic corporation, limited liability company, partnership, limited partnership,
or a limited liability partnership, complete and attach the formation documents prescribed by the secretary of state
for the specific entity type being created.
The authorized representative(s) identified below certify that the declaration of conversion is authorized
The authorized representative(s) identified below certify that the declaration of conversion is authorized
on behalf of the converting entity and that each person signing the certificate of conversion is authorized to do so.
REQUIRED
Signature
Date
Must be (signed) by an
authorized representative
Print Name
Title
Signature
Date
Print Name
Title
Form 800
Page 2 of 3
Last Revised: 12/01/2008
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Parent category: Legal