Statement Of Conversion Form - State Of Utah Department Of Commerce - 2014
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State of Utah
Department of Commerce
Print
Division of Corporations & Commercial Code
Statement of Conversion
Clear Form
Non-Refundable Processing Fee: $37.00
Pursuant to UCA § 48-3a-1045 causes this Statement of Conversion to be delivered to the Utah Division of
Corporations for filing, and states as follows:
1. The Statement of Conversion shall state:
Entity Number: _____________________________________
First: The name and entity type of the company immediately prior to the filing of the statement of
conversion:
Name: _______________________________________________________________________________
Entity Type (Corp, LLC, LP, Partnership, DBA, etc.): ________________________________
Second: The date and state where the company was first created and, if it has changed, its jurisdiction
immediately prior to its conversion:
_______________________________
_______________________________
Date of formation
State / Jurisdiction
Third: The name and entity type of the company as set forth in its converted entity filing;
Name: _______________________________________________________________________________
Entity Type: ________________________________
_______________________________
State / Jurisdiction
______________________________________________________________________________________
Registered Agent address or Utah mailing address for service of process if not qualified foreign LLC
Fourth: The plan of conversion was approved in accordance with Utah law or, if a foreign entity, the law
of the jurisdiction of its formation;
Fifth: The future effective date of the conversion to the new entity if it is not to be effective upon the
filing of the statement of conversion:
______________________________________________________________________________________
Sixth: Under penalties of perjury, I declare that the statement of conversion have been duly approved by
the owners of the entity.
Name: ______________________________
Signature: ___________________________
Sign here after the form is printed
Title:_______________________________
Date: _______________________________
2. Additional filing requirements: The non-refundable processing fee of $37.00 payable to the State of Utah,
and application for new entity must accompany this form. No additional fee for the new application.
Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you may
use the business entity physical address rather than the residential or private address of any individual affiliated with the entity.
Division's Website:
Mailing/Faxing Information:
/contactus.html
01/14
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