Statement Of Merger - Colorado Secretary Of State Page 3
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4Form of entity
______________________________________________________
Jurisdiction under which the
entity was formed
______________________________________________________
ID number
_____________________
(if applicable)
Principal office street address
______________________________________________________
(Street name and number)
______________________________________________________
__________________________ _____ ____________________
(City)
(State)
(Postal/Zip Code)
_______________________ ______________
(Province – if applicable)
(Country – if not US)
Principal office mailing address ______________________________________________________
(if different from above)
(Street name and number or Post Office Box information)
______________________________________________________
__________________________ _____ ____________________
(City)
(State)
(Postal/Zip Code)
_______________________ ______________
(Province – if applicable)
(Country – if not US)
3. The merging entities are merged into the surviving entity.
4. If one or more of the merging entities is a registrant of a trademark described in a filed document in the
records of the secretary of state, mark this box
and state below the document number of each such filed
document.
Document number
____________________
Document number
____________________
(If more than two trademarks, mark this box
and include an attachment stating the additional document numbers.)
5. Additional information may be included. If applicable, mark this box
and include an attachment stating
the additional information.
6. (Optional) Delayed effective date:
______________________
(mm/dd/yyyy)
Notice:
Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or
acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the
individual's act and deed, or that the individual in good faith believes the document is the act and deed of the
person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity
with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic
statutes, and that the individual in good faith believes the facts stated in the document are true and the
document complies with the requirements of that Part, the constituent documents, and the organic statutes.
This perjury notice applies to each individual who causes this document to be delivered to the secretary of
state, whether or not such individual is named in the document as one who has caused it to be delivered.
7. Name(s) and address(es) of the
MERGE
Page 3 of 4
Rev. 5/22/2007
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