Notice Of Exchange Transaction Or Entity Conversion Pursuant To Corporations Code Section 25103(H) - State Of California Commissioner Of Corporations
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1
2(Department of Corporations Use Only)
Department of Corporations File No., if any
Fee Paid $ ___________________
___________________________________
(Insert File Numbers(s) of Previous Filings
Receipt No. __________________
Before the Department, if any)
FEE: $600
(See Corporations Code Section 25608(z))
COMMISSIONER OF CORPORATIONS
STATE OF CALIFORNIA
NOTICE OF EXCHANGE TRANSACTION OR ENTITY CONVERSION
PURSUANT TO CORPORATIONS CODE SECTION 25103(h)
1.
Name of acquiring or converting entity (entity resulting from the conversion):
_____________________________________________________________________________________
2.
(a) Address of acquiring or converting entity:
_________________________________________________________________________
Street
City
State
Zip
(b)
Mailing address:
_________________________________________________________________________
Street
City
State
ZIP
(c)
Area code and telephone number: _____________________________________________
3.
Acquiring or converting entity's state or jurisdiction of incorporation or organization:
_____________________________________________________________________________________
4.
(a)
Name of entity to be acquired or converted: _____________________________________
(b)
State or jurisdiction of incorporation or organization of entity to be acquired or converted:
_____________________________________________________________________________________
5.
The exchange of securities meets the requirements of (check one):
( )
Section 25103(h)(1)(A) of the Code.
( )
Section 25103(h)(1)(B) of the Code, and the state of incorporation or organization is
_____________________, or the form of organization is _______________________________.
6.
Type of filing under the Securities Act of 1933, if applicable:
_______________________________________________________________________________
7.
Date of Notice: __________
_______________________________________________
( )
Check if acquiring or
Acquiring or converting entity
converting entity has
a consent to service of
___________________________________________________
process on file with
Authorized signature on behalf of acquiring or converting entity
the Commissioner
260.103.6(b) (Register No. 2009, No. 39)
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