Form Dscb:15-355 - Statement Of Conversion Page 2
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6. Check and complete one of the following addresses for the converting association.
If the converting association is a domestic filing association, 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 converting 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 converting association 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
B. For the converted association:
1. The name of the converted association is: __________________________________________________________
2. The jurisdiction of formation of the converted association is: ___________________________________________
3. 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 ____________________
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