Statement Of Correction - Pennsylvania Department Of State
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1PENNSYLVANIA DEPARTMENT OF STATE
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
Return document by mail to:
Statement of Correction
DSCB:15-138
Name
(rev. 7/1/2015)
Address
*138*
City
State
Zip Code
138
Return document by email to:
_________________________________
Read all instructions prior to completing. This form may be submitted online at https://
Fee: $70
In compliance with the requirements of 15 Pa.C.S. § 138 (relating to statement of correction), the undersigned
association or other person, desiring to correct an inaccurate, defective or erroneous record, hereby states that:
1. The name of the association or other person is: _________________________________________________________
2. The current registered office address as on file with the Department of State. 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
3. The statute by or under which the association was formed (or the preceding filing was made, in the case of a filing that
does not constitute a part of the public organic record of an association) is: ___________________________________
4. The inaccuracy or defect to be corrected is (include Department of State form name and date filed):
5. Check one of the following:
The portion of the document requiring correction in corrected form is set forth in Exhibit A attached hereto.
The original document to which this statement relates shall be deemed re-executed.
The original document to which this statement relates shall be deemed stricken from the records of the Department.
IN TESTIMONY WHEREOF, the undersigned association or other person has caused this Statement of Correction to be
signed by a duly authorized officer thereof or otherwise in its name this ______________ day of
____________________________, 20_______.
______________________________________
Name of Association
___________________________________________________
Signature
___________________________________________________
Title
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