Form 611a - Certificate Of Conversion To A Non-Rhode Island Entity - State Of Rhode Island Page 3
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3SECTION II:
TO BE COMPLETE BY ALL CONVERTING ENTITIES
Under penalty of perjury, I/we declare and affirm that I/we have examined this Certificate of Conversion, including any
accompanying attachments, and that all statements contained herein are true and correct.
Date:
Print Name of Other Entity
OR
Print Name of Partnership
By:
By:
Signature of Authorized Person
Signature of Partner
By:
By:
Signature of Authorized Person
Signature of Partner
By:
Signature of Partner
Print Name of Corporation
OR
Print Name of Sole Proprietorship
By:
By:
Signature of Authorized Person
Signature of Sole Proprietor
By:
Signature of Authorized Person
OR
Print Name of Limited Liability Company
By:
Signature of Authorized Person
By:
Signature of Authorized Person
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