Form Dscb:15-161/162e-2 - Bureau Of Corporations And Charitable Organizations Page 3

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Department of State
Bureau of Corporations and Charitable Organizations
P.O. Box 8722
Harrisburg, PA 17105-8722
(717) 787-1057
web site:
General Instructions for Completion of Form:
A. Typewritten is preferred. If not, the form shall be completed in black or blue-black ink in order to permit reproduction.
The fee for filing a Statement of Domestication is $125 and the fee for filing a Statement of Contingent
Domestication-Other is $1500 made payable to the
Commonwealth of Pennsylvania. Checks must
contain a commercially pre-printed name and address.
B. This form may be filed in the Department by electronic mail, facsimile transmission, telex or other similar means of
communication.
C. This form may be filed by an (alien) entity, such as an (alien) sole proprietorship which is not an association as defined
in 15 Pa.C.S. § 102 (relating to definitions).
D. This form shall be executed in the English language.
E. If the name of the entity is in a foreign language, the name as set forth in Paragraph 1 shall be set forth in Roman letters
or characters or in Arabic or Roman numerals.
F. The statement may be executed on behalf of the entity by any authorized person.
G. This form and all accompanying documents shall be mailed to the address stated above.
Instructions for Statement of Domestication Only:
I. The following, in addition to the filing fee, shall accompany this form: One copy of a completed form DSCB:15-134A
(Docketing Statement).
J. This form may not be filed by any association eligible to file form DSCB:15-4161/6161 (Articles of Domestication-
Foreign Corporation
Instructions for Statement of Contingent Domestication-Other Only:
K. The following, in addition to the filing fee, shall accompany this form:
(1) One copy of a completed form DSCB:15-134A (Docketing Statement).
(2) Any necessary copies of form DSCB:17.2.3 (Consent to Appropriation of Name). However, the filing of this
form will not prevent another association from later appropriating the name in view of the confidentiality
provisions of 15 Pa.C.S. § 162 (a).
(3) Any necessary Pennsylvania governmental approvals.
L. This form may not be filed by any association eligible to file DSCB:15-162A/162B/162C/162D (Statement of
Contingent Domestication-Foreign Business/Nonprofit Corporation/Limited Partnership/Limited Liability Company) or
by any entity governed by the laws of the United States, any state, Puerto Rico or any possession or territory of the
United States.
M. Annual renewal.-A renewal application may be filed between October 1 and December 31 in each year and shall

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