Form Dscb:15-366ad - Statement Of Division - Addendum printable pdf download

PENNSYLVANIA DEPARTMENT OF STATE

BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS

*366Ad*

Statement of Division - Addendum

DSCB:15-366AD

366Ad

(7/1/2015)

This form is used to identify additional resulting associations created by division

and must be submitted with the Statement of Division form (DSCB: 15-366).

B. For the resulting association(s) that are created by the division:

1. The name of the resulting association is: ____________________________________________________________

2. The jurisdiction of formation of the resulting association: ______________________________________________

3. The type of association is (check only one):

Business Corporation

Limited Partnership

Business Trust

Nonprofit Corporation

Limited Liability (General) Partnership

Professional Association

Limited Liability Company

Limited Liability Limited Partnership

Other ____________________

4. Check and complete one of the following addresses.

If the resulting association is a domestic filing association, domestic limited liability partnership or

registered foreign association, it registered office address. 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

If the resulting association is a domestic association that is not a domestic filing association or limited

liability partnership, the address, including street and number, if any, of its principal office:

____________________________________________________________________________________________________

Number and street

City

State

Zip

County

If the resulting association is a nonregistered foreign association, the address, including street and number, if

any, of its registered or similar office, if any, required to be maintained by the law of its jurisdiction of formation;

or if it is not required to maintain a registered or similar office, its principal office address:

____________________________________________________________________________________________________

Number and street

City

State

Zip

5. The property and liabilities of the dividing association that are to be allocated to this resulting association are:

________________________________________________________________________________________________________

See DSCB:15-366 Instruction E for attachments which must accompany this form for each new resulting entity.

Form Dscb:15-366ad - Statement Of Division - Addendum

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