Form Dscb:15-375 - Statement Of Domestication Template - Pennsylvania Department Of State Bureau Of Corporations And Charitable Organizations

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PENNSYLVANIA DEPARTMENT OF STATE
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
Return document by mail to:
Statement of Domestication
DSCB:15-375
Name
(7/1/2015)
Address
*375*
City
State
Zip Code
375
Return document by email to:
_________________________________
Read all instructions prior to completing.
Fee: $70
In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 375 (relating to Statement of
domestication), the undersigned entity, desiring to effect domestication, hereby states that:
A. For the domesticating entity:
1. 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 ___________________
2. The name of the domesticating entity is: ______________________________________________________________
3. The jurisdiction of formation of the domesticating entity: _________________________________________________
4. Date on which the domesticating entity was created, incorporated or formed: _________________________________
(MM/DD/YYYY)
5. Check and complete one of the following addresses.
If the domesticating entity is a domestic filing entity, domestic limited liability partnership or registered
foreign association, the current registered office address as on file with the Department of State.
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 domesticating entity is a domestic entity that is not a domestic filing entity 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 domesticating entity is a nonregistered foreign association, 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:
____________________________________________________________________________________________________
Number and street
City
State
Zip

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