Form 611a - Certificate Of Conversion To A Non-Rhode Island Entity - State Of Rhode Island Page 2
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3Filing Fee: $50.00
ID # ____________________
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Office of the Secretary of State
Division of Business Services
148 W. River Street
Providence, Rhode Island 02904-2615
CERTIFICATE OF CONVERSION TO A NON-RHODE ISLAND ENTITY
(Insert full name of the entity following the conversion)
SECTION I: TO BE COMPLETED BY ALL CONVERTING ENTITIES
Pursuant to the applicable provisions of the Rhode Island General Laws, 1956, as amended, the undersigned (check one
box only):
Limited Liability Company
or
Business Corporation
submits the following Certificate of Conversion for the purpose of converting to a non-Rhode Island Entity (check one box
only):
“Other entity” or
Business Corporation or
Sole Proprietorship or
Partnership (General, Limited, or Limited Liability Partnership) or
Limited Liability Company
a. The name of the converting entity filing this Certificate of Conversion is:
If the entity’s name has been changed, the name under which it was originally organized:
b. The date on which the converting entity was first created, formed, or otherwise came into being is:
The jurisdiction to which the entity is converting is:
c.
d. The name of the entity following the conversion is:
e. This conversion has been approved in the manner provided for in §§ 7-1.2-1008 and 7-16.5.2(e) of the Rhode
Island General Laws, 1956, as amended.
f.
The converting entity revokes the authority of its registered/resident agent in this state to accept service of
process, and consents that service of process in any action, suit, or proceeding based upon any cause of action
arising in this state during the time the entity was authorized to transact business in this state may subsequently
be made on the entity by service thereof on the Secretary of State of the State of Rhode Island, to which the
converting entity irrevocably appoints the Secretary of State as it’s agent to accept such service of process.
g. The address to which the Secretary of State may mail a copy of any process against the entity that is served on
the Secretary of State:
h. The future date or time certain of the conversion is:
Form 611A
Revised: 06/11
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