Form Dscb:15-161 - Statement Of Domestication - Other printable pdf download

PENNSYLVANIA DEPARTMENT OF STATE

BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS

Return document by mail to:

Statement of Domestication - Other

DSCB:15-161

Name

(7/1/2015)

Address

*161*

City

State

Zip Code

161

Return document by email to:

_________________________________

Read all instructions prior to completing.

Fee: $70

In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 161 (relating to domestication of

certain alien associations), the undersigned association, desiring to become a domestic association, hereby states that:

1. The name of the association is: _____________________________________________________________________

2. The date on which the association was first formed, incorporated or otherwise came into being is: _________________

3. The name of the jurisdiction under the laws of which it was first formed, incorporated or otherwise came into being is:

4. The name of the jurisdiction that constituted the seat, siege social or principal place of business or control

administration of the entity, or any equivalent under applicable law, immediately prior to the filing of this statement is:

5. Upon domestication, the association will be a domestic association under the laws of the Commonwealth of

Pennsylvania. Specify type of association: _______________________________________________________________

6. The (a) address of the association’s proposed registered office in this Commonwealth or (b) name of its commercial

registered office provider and the county of venue is: Complete part (a) OR (b) – not both:

(a) _____________________________________________________________________________________________________

Number and street

City

State

Zip

County

(b) c/o: __________________________________________________________________________________________________

Name of Commercial Registered Office Provider

County

7. The filing of this statement has been authorized by a majority in interest of the interest holders of the association or by

any greater vote required by its organic rules.

8. Optional statement – please check box if applicable.

The renunciation of the prior domicile of the undersigned association has been authorized by a majority in interest

of the interest holders of the association or by any greater vote required by its organic rules.

IN TESTIMONY WHEREOF, the undersigned association has caused this Statement of Domestication - Other to be

signed by a duly authorized officer thereof this ______________ day of ____________________________ 20_______.

______________________________________

Name of Association

______________________________________

Signature

______________________________________

Title

Form Dscb:15-161 - Statement Of Domestication - Other

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