Looking for a U.s. Department Of State Forms And Templates? Download it for free!

Microfilm Number

Filed with the Department of State on_______________

Entity Number____________________

_____________________________________________

Secretary of the Commonwealth

STATEMENT OF CONTINGENT DOMESTICATION-FOREIGN NONPROFIT CORPORATION

DSCB:15-162B (Rev 90)

In compliance with the requirements of 15 Pa.C.S. § 162 (relating to contingent domestication of certain foreign associations),

the undersigned foreign nonprofit corporation, desiring to become a contingent domestic association, hereby states that:

1. The name of the corporation is:_______________________________________________________________________________

________________________________________________________________________________________________________

2. The (a) address of this corporation's current registered office in this Commonwealth or (b) name of its commercial registered

office provider and the county of venue is (the Department is hereby authorized to correct the following information to

conform to the records of the Department):

(a) ___________________________________________________________________________________________________

Number and Street

City

State

Zip

County

(b) c/o:_________________________________________________________________________________________________

Name of Commercial Registered Office Provider

County

For a corporation represented by a commercial registered office provider, the county in (b) shall be deemed the county in which the

corporation is located for venue and official publication purposes.

3. Upon domestication the corporation will be subject to the domestic corporation provisions of the Nonprofit Corporation Law of 1988.

4. The purpose or purposes for which the corporation is to be domesticated in the Commonwealth of Pennsylvania are:

________________________________________________________________________________________________________

5. (Strike out if inapplicable): This Statement of Contingent Domestication includes the additional provisions set forth in full in

Exhibit A attached hereto and made a part hereof.

6. The effectiveness of this Statement of Contingent Domestication is contingent upon the subsequent filing of a Statement of

Consummation of Domestication.

7. The filing of this Statement of Contingent Domestication and the delegation of authority to file a Statement of Consummation

Domestication on behalf of the undersigned corporation has been authorized by a majority vote of the votes cast by all

members, if any, entitled to vote thereon and, if any class of members is entitled to vote thereon as a class, a majority of the votes cast

in each class vote, or by any greater vote required by its charter.

IN TESTIMONY WHEREOF, the undersigned corporation has caused this Statement of Contingent Domestication to be executed

this

day of

___________________________________

(Name of Corporation)

BY:________________________________

(Signature)

TITLE: _____________________________

Form Dscb:15-162b - Statement Of Contingent Domestication-Foreign Nonprofit Corporation