Form 15-134b - Docketing Statement Template

Form 15-134b - Docketing Statement Template - 1995 Page 3

DSCB:15-134B (Rev 95)-3

____Section D. DIVISION (Forming NEW entity(s) named below. Also, complete and attach DOCKETING STATEMENT

DSCB:15-134A for EACH new entity formed by division.)

_____________________________1. ___________________________________________________________

Entity Number

Name

_____________________________2. ___________________________________________________________

Entity Number

Name

Attach sheet if there are additional entities to be named.

CHECK ONE :

____Entity named in Part I survives. (Any changes, complete Section A)

____Entity named in Part I does not survive.

____Section E.

CONVERSION (Complete Section A)

CHECK ONE :

____Converted from nonprofit to profit

____Converted from profit to nonprofit

____Section F.

DISSOLVED BY SHAREHOLDERS OR INCORPORATORS BEFORE COMMENCEMENT OF BUSINESS

____Section G.

STATEMENT OF REVIVAL Entity named in Part I hereby revives its charter or articles which were

forfeited by Proclamation or expired. (Complete Section A if any changes have

been made to the revived entity.)

____Section H.

STATEMENT OF TERMINATION

filed in the Department of State on

is/are hereby terminated.

(type of filing made)

month

day year

hour, if any

If merger, consolidation or division, list all entities involved, other than that listed in Part I:

_____________________________1. ___________________________________________________________

Entity Number

Name

_____________________________2. ___________________________________________________________

Entity Number

Name

Attach sheet containing above information if there are additional entities involved.

Form 15-134b - Docketing Statement Template - 1995 Page 3