Form Dscb:15-161/162e-2 - Bureau Of Corporations And Charitable Organizations

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PENNSYLVANIA DEPARTMENT OF STATE
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
Statement of Domestication
(15 Pa.C.S. § 161)
Statement of Contingent Domestication-Other
(15 Pa.C.S. § 162E)
Document will be returned to the
Name
name and address you enter to
the left.
Address
City
State
Zip Code
Fee: $125 - Domestication
$1500 – Contingent Domestication
In compliance with the requirements of the applicable provisions (relating to domestication of certain alien associations/
contingent domestication of certain foreign associations), the undersigned entity, desiring to become a domestic association/contingent
domestic association, hereby states that:
1. The name of the entity is:
.
2
The name of the jurisdiction under the laws of which it was first formed, incorporated or otherwise came into
being is:
3. The date on which it was first formed, incorporated or otherwise came into being is:
4. The name of the jurisdiction that constituted the seat, siege social or principal place of business or control
administration of the entity, or any equivalent under applicable law, immediately prior to the filing of this
statement was:
5. Upon domestication the entity will be a domestic association under the laws of the Commonwealth of
Pennsylvania.

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