Form Dscb:15-345 - Statement Of Interest Exchange Page 2
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B. For the acquiring association:
1. The name of the acquiring association is: ___________________________________________________________
2. The jurisdiction of formation of the acquiring association: ______________________________________________
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 acquiring 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 acquiring 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 acquiring 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 address:
____________________________________________________________________________________________________
Number and street
City
State
Zip
C. Effective date of statement of interest exchange (check, and if appropriate complete, one of the following):
This Statement of Interest Exchange shall be effective upon filing in the Department of State.
This Statement of Interest Exchange shall be effective on: _________________________ at ________________.
Date (MM/DD/YYYY)
Hour (if any)
D. Approval of interest exchange by acquired association:
The plan of interest exchange was approved in accordance with 15 Pa.C.S. Chapter 3, Subchapter D (relating to interest
exchange).
IN TESTIMONY WHEREOF, the undersigned acquired association has caused this Statement of Interest Exchange to be
signed by a duly authorized officer thereof this ______________ day of __________________________, 20__________.
______________________________________________
Name of Acquired Association
___________________________________________________
Signature
___________________________________________________
Title
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