Annual Statement - Nonprofit Corporation - Pennsylvania Department Of State
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1PENNSYLVANIA DEPARTMENT OF STATE
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
Return document by mail to:
Annual Statement - Nonprofit Corporation
DSCB:15-5110
Name
(rev. 7/2015)
Address
*5110*
City
State
Zip Code
5110
Return document by email to:
_________________________________
Read all instructions prior to completing. This form may be submitted online at https://
Fee: None
In compliance with the requirements of 15 Pa.C.S. § 5110 (relating to annual report), the undersigned domestic or
qualified foreign nonprofit corporation, hereby states that:
1. The name of the corporation is:
2. The address of its principal office is:
Number and street
City
State
Zip
County
3. The names and title of the persons who are its principal officers are:
Names
Titles
IN TESTIMONY WHEREOF, the undersigned corporation
has caused this Annual Statement to be signed by a duly
authorized officer thereof this
day of
,
.
_____________________________________________________
Name of Corporation
Signature
_________________________________________________
Title
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