Form Dscb:15-345 - Statement Of Interest Exchange
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2PENNSYLVANIA DEPARTMENT OF STATE
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
Return document by mail to:
Statement of Interest Exchange
DSCB:15-345
Name
(7/1/2015)
Address
*345*
City
State
Zip Code
345
Return document by email to:
_________________________________
Fee:
$70
In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 345 (relating to Statement of
interest exchange), the undersigned acquired domestic entity, desiring to effect an interest exchange, hereby states that:
A. For the acquired association:
1. The name of the acquired association is: ___________________________________________________________
2. The jurisdiction of formation of the acquired association is Pennsylvania.
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 ____________________
4. Check and complete one of the following addresses.
If the acquired association is a domestic filing association or domestic limited liability partnership, 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 acquired 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
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