Form 08-489 - Application For Certificate Of Conversion-Domestic Limited Liability Company - Juneau - 2013 Page 2

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State of Alaska
DO NOT STAMP ABOVE THIS BOX
Division of Corporations, Business and Professional Licensing
CORP
Office Use Only
CORPORATIONS SECTION
PO Box 110806
Juneau, AK 99811-0806
Phone: (907) 465-2550
Fax: (907) 465-2974
Website:
APPLICATION FOR CERTIFICATE OF CONVERSION
Domestic Limited Liability Company
AS 10.50.570
$25.00 Filing Fee (non-refundable)
NOTICE: The Certificate of Conversion must be filed in conjunction with Articles of Organization for a Domestic
Limited Liability Company and the applicable $250.00 fee – see form 08-484.
Pursuant to the provisions of Alaska Statutes 10.50.570, the undersigned hereby applies for a Certificate of
Conversion to transact business as a limited liability company in the State of Alaska.
ITEM 1: Name of the entity before the filing of the certificate of conversion to a limited liability company:
ITEM 2: Name of the limited liability company as stated in its articles of organization:
ITEM 3: State or country where the entity was originally formed:
ITEM 4: Date and the jurisdiction where the other entity was first came into being:
Date:
Jurisdiction:
ITEM 5: Effective date of conversion if deferred from date of filing (mm/dd/yyyy format): ___/___/_____
ITEM 6: The Certificate of Conversion must be signed by one or more persons organizing the conversion of the
LLC.
Signature
Printed name
Title
Date
NOTE: Persons who sign documents filed with the commissioner that are known to the person to be false in
material respects are guilty of a class A misdemeanor.
Please note: The following only applies to business corporations as defined in AS 10.50.570(j):.By filing the
Certificate of Conversion, all officials currently on record will be removed on the date the conversion is to take
effect. To add members and/or managers please complete the Change of Officials form, the fee is $25.
Mail the Conversion and non-refundable $25.00 filing fee, along with Articles of Organization and $250.00 to:
State of Alaska, Corporations Section, PO Box 110806, Juneau, AK 99811-0806
STANDARD PROCESSING TIME for complete and correct applications submitted to this office is
approximately 10-15 business days. All applications are reviewed in the date order they are received.
08-489 (Rev. 03/22/2013)
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