Fees will increase September 1, 2003. If you file this report
before September 1, the fee is $20.00. If you file this report
after September 1, the fee is $35.00.
Contact Information
KANSAS SECRETARY OF STATE
CV
Kansas Secretary of State
Certificate of Conversion
Ron Thornburgh
53-13
Memorial Hall, 1st Floor
All information must be completed or this document will not be accepted for filing.
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
Print
Reset
Please complete the form, print, sign and
A general partnership, limited liability partnership (LLP), limited partner-
mail to the Kansas Secretary of State with
ship (LP), limited liability limited partnership(LLLP), business trust/asso-
the filing fee. Selecting 'Print' will print
ciation, real estate investment trust, common-law trust, foreign limited li-
ability company, or any other unincorporated business may convert to a
the form and 'Reset' will clear the entire
Kansas LLC by certifying the following information:
form.
1. Date and jurisdiction where the entity was formed, and, if the jurisdiction
Do not write in this space
has changed, the jurisdiction immediately prior to this conversion:
___________________________________________________________________________________________________________
2. Name of the converting entity:
___________________________________________________________________________________________________________
3. Future effective date of conversion if not effective upon filing, but not later than 90 days after the filing date:
_________________
____________
___________
Month
Day
Year
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed on the ________ of ___________ , _____________
.
Day
Month
Year
Authorized person
Instructions
1. Submit this form in duplicate with the $35 filing fee.
2. Attach articles of organization for the new LLC, form DL with the $165 filing fee.
Notice: There is a $25 service fee for all returned checks.
Rev. 8/11/03 amc
K.S.A. 17-7684