Statement Form Of Contingent Domestication-Foreign Limited Liability Company

Microfilm Number

Filed with the Department of State on

Entity Number

__________________________________________________

Secretary of the Commonwealth

STATEMENT OF CONTINGENT DOMESTICATION-FOREIGN LIMITED LIABILITY COMPANY

DSCB:15-162D (Rev 95)

In compliance with the requirements of 15 Pa.C.S. § 162 (relating to contingent domestication of certain foreign associations),

the undersigned foreign limited liability company, desiring to become a contingent domestic association, hereby states that:

1. The name of the limited liability company is:

_____

2. The (a) address of this limited liability company's current registered office in this Commonwealth or (b) name of its commercial

registered office provider and the county of venue is (the Department is hereby authorized to correct the following information to

conform to the records of the Department):

(a)

Number and Street

City

State

Zip

County

(b) c/o:

Name of Commercial Registered Office Provider

County

For a limited liability company represented by a commercial registered office provider, the county in (b) shall be deemed the county

in which the limited liability company is located for venue and official publication purposes.

3. Upon domestication the limited liability company will be subject to the domestic limited partnership provisions of the Limited

Liability Act of 1994.

4. The purpose or purposes for which the limited liability company is to be domesticated in the Commonwealth of Pennsylvania

are:

_____________________________________________________________________________________________________

_____________

5. (Strike out if inapplicable): This Statement of Contingent Domestication includes the additional provisions set forth in Exhibit

A attached hereto and made a part hereof.

6. The effectiveness of this Statement of Contingent Domestication is contingent upon the subsequent filing of a Statement of

Consummation of Domestication.

7. The filing of this Statement of Contingent Domestication and the delegation of authority to file a Statement of Consummation of

Domestication on behalf of the undersigned limited liability company has been authorized by a majority vote of the votes cast by all

members entitled to vote thereon and, if any class of members is entitled to vote thereon as a class, a majority of the votes cast in

each class vote subject to § 8982.

IN TESTIMONY WHEREOF, the undersigned limited liability company has caused this Statement of Contingent

Domestication to be executed this

day of

____________________________________

(Name of Company)

BY:_________________________________

(Signature)

TITLE:_______________________________

Statement Form Of Contingent Domestication-Foreign Limited Liability Company - 1995

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