Form Ss-4269 - Certificate Of Conversion (Llc Into Another Business Entity) Form - Department Of State - Tennessee

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For Offi ce Use Only
CERTIFICATE OF CONVERSION
(LLC into another Business Entity)
Corporate Filings
312 Eighth Avenue North
th
6
Floor, William R. Snodgrass Tower
Nashville, TN 37243
Pursuant to the provisions of §48-249-704 of the Tennessee Revised Limited Liability Company Act, the
undersigned Limited Liability Company submits this certifi cate of conversion:
1. The current name of the of the domestic limited liability company (hereinafter referred to as the domestic
LLC) is:
.
If different, the name of the domestic LLC under which its articles of organization were originally fi led is:
.
2. The date of fi ling of the original articles of organization of the domestic LLC was:
(month/day/year).
3. The name of the other business entity into which the domestic LLC is to be converted is
, its jurisdiction of formation is
, and its
business type is a
.
4. All required approvals of the conversion have been obtained by the domestic limited liability company.
5. If the conversion is not to be effective upon the fi ling of the certifi cate of conversion, then the future effective
date or time of the conversion is:
Date:
,
Time
6. The following box must be checked and the mailing address provided if the domestic LLC is converting
to a foreign entity:
The foreign entity agrees that it may be served with process in this State in any proceeding for the enforce-
ment of any obligation of the domestic LLC arising prior to the date of the conversion, irrevocably appointing
the Secretary of State as its agent to accept service of process in any such proceeding. The address (includ-
ing zip code) to which a copy of such process shall be mailed to it by the Secretary of State is:
.
Signature date
Signature
Signer’s capacity
Name (typed or printed)
Filing Fee $20
SS-4269 (Rev. 06/07)
RDA 2458

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