Form 15-134b - Docketing Statement Template - 1995 printable pdf download

Form 15-134b - Docketing Statement Template - 1995

(CHANGES)

BUREAU USE ONLY :

DOCKETING STATEMENT DSCB:15-134B (Rev 95)

REVENUE

LABOR & INDUSTRY

OTHER

FILING FEE: NONE

FILE CODE

FILED DATE

This form (file in triplicate) and all accompanying documents shall be mailed to:

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF STATE

CORPORATION BUREAU

P.O. BOX 8722

HARRISBURG, PA 17105-8722

Part I. COMPLETE FOR EACH FILING:

Current name of entity or registrant affected by the submittal to which this statement relates: (survivor or new entity if merger or

consolidation)

Entity number, if known:

NOTE: ENTITY NUMBER is the computer index number assigned to an entity upon initial

filing in the Department of State.

Incorporation/qualification date in Pa.:

State of Incorporation:

Federal Identification Number:

Specified effective date, if any:

Part II. COMPLETE FOR EACH FILING This statement is being submitted with (check proper box):

____Amendment: complete Section A only

____Merger, Consolidation or Division: complete Section B, C or D

____Consolidation: complete Section C

____Division: complete Section D

____Conversion: complete Section A and E only

____Statement of Correction: complete Section A only

____Statement of Termination: complete Section H

____Statement of Revival: complete Section G

____Dissolution by Shareholders or Incorporators before Commencement of Business: complete Section F only

Part III. COMPLETE IF APPROPRIATE: The delayed effective date of the accompanying submittal is:

month

day

year

hour, if any

Form 15-134b - Docketing Statement Template - 1995